Erb's Palsy

Overview

What is Erb’s palsy?

Erb’s palsy is a nerve condition in the shoulder and arm that results in weakness or loss of muscle function. The brachial plexus is a group of five nerves that connect the spine to the arm and hand. These nerves allow your shoulder, arms and hands to feel and move. If these brachial plexus nerves don’t work well due to stretching or tearing, the condition is called a brachial plexus palsy. Erb's palsy is the most common type of brachial plexus palsy. It involves the upper nerves in the plexus. Palsy is another name for partial or complete loss of muscle function — muscle weakness or paralysis.

Erb’s palsy is also known as Erb-Duchenne paralysis.

What types of injuries are common with Erb’s palsy?

There are four types of brachial plexus injuries:

  • Avulsion is when the nerve rips away from the spine and is the most serious type of Erb's palsy.
  • Rupture is when the nerve is torn, but not from the spine.
  • Neuroma is when the nerve has torn and healed but has left scar tissue. The scarred tissue puts pressure on the injured nerve and prevents it from conducting signals to the muscles.
  • Neurapraxia is when the nerve is stretched but not torn. Neurapraxia is the most common type of brachial plexus injury.

Who does Erb’s palsy affect?

Newborns sometimes develop Erb’s palsy during a difficult vaginal childbirth, or even during a cesarean section. During delivery, your healthcare provider sometimes has to move your baby’s head to one side to make room for delivery of their shoulders. In some cases, the stretching of the nerves causes damage, possibly even tears. This type of Erb’s palsy is also called a brachial plexus birth palsy, obstetric brachial plexus palsy or brachial plexus birth injury.

Erb’s palsy can also happen to adults who have traumatic injuries.

How common is Erb’s palsy (brachial plexus birth palsy) in newborns?

Erb’s palsy occurs in 0.9 to 2.6 per 1,000 live births or nearly 12,000 cases per year. It's most common in larger infants who need to be pulled out during delivery because they’re stuck.

Symptoms and Causes

What are the signs and symptoms of Erb’s palsy?

Erb’s palsy affects the shoulder, arm and elbow. In general, your hand muscles aren’t affected, but your hands may experience tingling or numbness.

Signs and symptoms of Erb’s palsy include:

  • Paralysis or limpness of the shoulder, arm and elbow. You can’t lift your arm away from your body or bend your elbow.
  • Numbness or tingling in your arm or hand. These are also known as “burners and stingers.”
  • A hand position known as ‘the waiter’s tip’ position. The palm of your hand points toward the back, and the fingers curl.

What causes Erb’s palsy in newborns?

A newborn may develop Erb’s palsy during delivery. Sometimes, your healthcare provider has to shift your baby’s head to one side during birth to get their shoulders out. The brachial plexus nerves from the neck to the shoulder may stretch or even tear. A newborn can also develop Erb's palsy due to the way they were lying in the uterus (womb) during pregnancy and once labor begins.

What causes Erb’s palsy (brachial plexus injuries) in adults?

Traffic accidents, most often those involving motorcycles, are the most common cause of brachial plexus injuries in teenagers and adults. Other causes of these injuries include gunshot or knife wounds, industrial accidents, accidents related to contact sports like football, surgical complications or tumors. These types of injuries are more likely to happen to men.

Diagnosis and Tests

How is Erb’s palsy diagnosed?

The diagnosis usually begins with a physical examination. Your healthcare provider might also order these tests:

  • EMG (electromyography). This test finds out how well muscles and nerves work.
  • Imaging tests. These tests take pictures of what’s happening inside your body. Your provider may order an MRI or a CT combined with myelogram. Your provider might also order an X-ray if there is any question about broken bones.

Management and Treatment

How is Erb’s palsy treated?

Treatment of Erb’s palsy depends partly on how severe the injury is. Some cases resolve by themselves within three to four months. But, most likely, your healthcare provider will suggest that you do exercises and physical therapy with your baby from about the age of three weeks.

The range-of-motion and stretching exercises will help prevent stiffness in your baby's arm, hand and wrist. You’ll want to avoid a joint contracture (permanent joint stiffness). Follow your provider’s instructions about how many times to do the movements each day.

Hydrotherapy combines exercise with water. The water provides support that makes exercise less painful.

Your provider might inject botulinum toxin (Botox®) to paralyze working muscles for a time to force weaker muscles to take over. They might also splint your baby’s hand to prevent it from curling inward and being rigid.

If the palsy hasn’t improved before your baby is 6 months old, your provider might recommend surgery, including:

  • Nerve repair. These surgeries include nerve grafts, nerve transfers, neurolysis and nerve decompression.
  • Muscle repair. This involves a muscle or tendon transfer to replace the damaged tissue with tissue from another place in the body.

It’s important to realize that any type of nerve repair and regrowth happens slowly — the results aren’t immediate.

Prevention

How can I reduce the risk of my newborn having Erb’s palsy?

There are certain risk factors related to shoulder dystocia (a baby’s shoulder being stuck inside the mother’s pelvis, which is related to Erb’s palsy). These factors include:

  • High infant birth weight and/or a gestational parent with overweight/obesity.
  • Diabetes in the gestational parent (either diabetes that was there before pregnancy or gestational diabetes).
  • A previous pregnancy involving shoulder dystocia.
  • Being pregnant with more than one baby.
  • Getting medications like oxytocin or an epidural during labor.
  • Breech birth position (your baby isn’t head-first in the birth canal).

How can an adult reduce their risk for Erb’s palsy?

You can possibly reduce your risk for developing a brachial plexus injury by wearing protective equipment if you participate in contact sports or riding motorcycles.

Outlook / Prognosis

What can I expect if I have Erb’s palsy or if my child has Erb’s palsy?

Some cases of Erb’s palsy resolve on their own. Other cases respond so well to early treatment that their shoulder and arm move normally.

If someone with Erb’s palsy doesn’t recover function early and doesn't have corrective surgery, they will probably find that their arm and shoulder don’t move normally later on.

There are support organizations for people with Erb’s palsy and their families. You might find it helpful to contact these groups.

Is Erb’s palsy fatal?

No, Erb’s palsy is a nerve condition that results in weakness or loss of muscle function in your arm or shoulder. It's not fatal.

Living With

When should I see my healthcare provider about Erb’s palsy?

The longer a nerve injury remains untreated, the more difficult it may be to achieve an optimal outcome. Therefore, early on, you should see a specialist who can follow you or your infant to monitor your recovery and determine if intervention is necessary.

If you’re the parent of an infant with Erb’s palsy, you’ll likely have follow-up visits. It’s important to keep those appointments. However, if anything gets worse outside of these appointments, call your child's provider.

That holds true if you’re an adult with Erb’s palsy. Let your healthcare provider know if anything seems worse, if you’re having trouble with the exercises, or if you have any other concerns.

Frequently Asked Questions

What is the difference between Erb’s palsy and Klumke’s palsy?

The two conditions are similar in that they're both injuries that happen to the brachial plexus. However, the nerve damage in Erb’s palsy happens to the upper nerves and affects your arm. The nerve damage in Klumke’s palsy happens to the lower nerves. The lower brachial plexus nerves affect the muscles in the forearm and the hand. Sometimes the hand will have a claw appearance. Klumke’s palsy is also known as Klumke-Dejerine palsy or paralysis.

A note from Cleveland Clinic

Erb’s palsy is the name for a certain type of injury to the brachial plexus nerves. It most frequently occurs during childbirth, but adults can get it too. The injury affects the movement of your shoulder and arm — they might be paralyzed. However, many infants who have this condition can recover on their own. If your baby doesn’t recover right away, discuss your concerns with your healthcare provider. Make sure that you know exactly how to do the exercises your healthcare provider suggests. Do them on the correct schedule and keep your appointments.

Last reviewed by a Cleveland Clinic medical professional on 10/20/2021.

References

  • Erb and Klumpke Palsy. In: Bissonnette B, Luginbuehl I, Engelhardt T. eds. Syndromes: Rapid Recognition and Perioperative Implications, 2e. McGraw Hill.
  • American Association of Neuromuscular & Electrodiagnostic Medicine. Erb’s Palsy. (https://www.aanem.org/Patients/Muscle-and-Nerve-Disorders/Erb-s-Palsy) Accessed 10/20/2021.
  • National Institute of Neurological Disorders and Stroke. Erb-Duchenne and Dejerine-Klumpke Palsies Information Page. (https://www.ninds.nih.gov/Disorders/All-Disorders/Erb-Duchenne-and-Dejerine-Klumpke-Palsies-Information-Page) Accessed 10/20/2021.
  • Basit H, Ali CDM, Madhani NB. Erb Palsy. (https://www.ncbi.nlm.nih.gov/books/NBK513260/) [Updated 2021 May 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Accessed 10/20/2021.
  • Thatte MR, Babhulkar S, Hiremath A. Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. Ann Indian Acad Neurol. 2013;16(1):26-33. doi:10.4103/0972-2327.107686
  • March of Dimes. Shoulder Dystocia. (https://www.marchofdimes.org/complications/shoulder-dystocia.aspx) Accessed 10/20/2021.
  • American Academy of Orthopaedic Surgeons. Erb's Palsy (Brachial Plexus Birth Palsy) (https://orthoinfo.aaos.org/en/diseases--conditions/erbs-palsy-brachial-plexus-birth-palsy) ). Accessed 10/20/2021.
  • United Brachial Plexus Network. Multiple pages reviewed for this article. What is a Brachial Plexus Injury? (https://ubpn.org/what-is-bpi) Accessed 10/20/2021.

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