Erb's palsy: Difference between revisions

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{{SI}}
{{SI}}
{{CMG}}; {{AE}}[[Moises Romo|Moises Romo, M.D.]],   
{{CMG}}; {{AE}}[[Moises Romo|Moises Romo, M.D.]], Fahime Shojaei, M.D.  
 
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==Overview ==
==Overview ==
Duchenne-Erb's palsy, or simply Erb's palsy, is a form of brachial plexus birth palsy (BPBP). It occurs when there is a stretching of the superior brachial plexus (neuropraxia, neuroma, rupture, avulsion) during delivery, leading in most of the cases to a temporal weakness and loss of sensation in certain muscles of the upper extremity.
Duchenne-Erb's [[palsy]] or simply Erb's palsy, is a [[lesion]] to the C5-C6 brachial roots; it can be a form of [[brachial plexus birth palsy (BPBP)]] or can be acquired in adulthood. It occurs when there is a stretching of the [[superior brachial plexus]] ([[neuropraxia]], [[neuroma]], [[neurotmesis]]), leading in most of the cases to a temporal [[Muscle weakness|weakness]] and [[Hypoesthesia|loss of sensation]] in certain muscles of the [[Upper limb|upper extremity]].      
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==Historical Perspective==
==Historical Perspective==
Erb's palsy, was first discribed by William Smellie, a British obsterician, in 1754 on his midwifery book, "''Traité de la theorie et pratique des accouchemens"''.<ref name="pmid7743291">{{cite journal| author=Dunn PM| title=Dr William Smellie (1697-1763), the master of British midwifery. | journal=Arch Dis Child Fetal Neonatal Ed | year= 1995 | volume= 72 | issue= 1 | pages= F77-8 | pmid=7743291 | doi=10.1136/fn.72.1.f77 | pmc=2528415 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7743291  }}</ref>  
Erb's palsy, was first described by [[William Smellie]], a British obstetrician, in 1754 on his midwifery book, "''Traité de la theorie et pratique des accouchemens"''.<ref name="pmid77432913">{{cite journal| author=Dunn PM| title=Dr William Smellie (1697-1763), the master of British midwifery. | journal=Arch Dis Child Fetal Neonatal Ed | year= 1995 | volume= 72 | issue= 1 | pages= F77-8 | pmid=7743291 | doi=10.1136/fn.72.1.f77 | pmc=2528415 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7743291  }}</ref>


In 1861, French neurologist, Guillaume Benjamin Amand Duchenne was the first to discover the association of paralysis in the same muscles (deltoid, biceps, and subescapularis) of arms and shoulders of infants delivered vaginally, naming it "obstetric palsy of the brachial plexus".
In 1861, French [[neurologist]], [[Guillaume Benjamin Amand Duchenne]] was the first to discover the association of [[paralysis]] in the same muscles ([[deltoid]], [[biceps]], and [[Subscapularis muscle|subscapularis]]) of arms and shoulders of infants delivered vaginally, naming it "obstetric palsy of the brachial plexus".<ref>{{Cite book|title="De l'éléctrisation localisée et de son application à la pathologie et à la thérapeutique"|last=Duchenne|first=Guillaume|publisher=Baillière|year=1855|isbn=|location=France|pages=}}</ref><ref>{{Cite web|url=https://en.wikipedia.org/wiki/Erb%27s_palsy|title=Erb's palsy|last=|first=|date=|website=Wikipedia|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref>


In 1874, German neurologist, Wilhelm Heinrich Erb concluded that paralysis was associated with a radicular lesion at the level of the superior plexus,C5-C6, and not from isolated peripheral nerve lesions.<ref name="pmid17575018">{{cite journal| author=Sarikcioglu L, Arican RY| title=Wilhelm Heinrich Erb (1840-1921) and his contributions to neuroscience. | journal=J Neurol Neurosurg Psychiatry | year= 2007 | volume= 78 | issue= 7 | pages= 732 | pmid=17575018 | doi=10.1136/jnnp.2007.115956 | pmc=2117688 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17575018  }}</ref><ref name="pmid21955966">{{cite journal| author=McGillicuddy JE| title=Neonatal brachial plexus palsy - historical perspective. | journal=J Pediatr Rehabil Med | year= 2011 | volume= 4 | issue= 2 | pages= 99-101 | pmid=21955966 | doi=10.3233/PRM-2011-0161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21955966  }}</ref><br />
In 1874, German neurologist, [[Wilhelm Heinrich Erb]] concluded that paralysis was associated with a [[Radiculopathy|radicular]] lesion at the level of the [[superior plexus]], C5-C6, and not from isolated [[Peripheral nervous system|peripheral nerve]] lesions.<ref name="pmid175750183">{{cite journal| author=Sarikcioglu L, Arican RY| title=Wilhelm Heinrich Erb (1840-1921) and his contributions to neuroscience. | journal=J Neurol Neurosurg Psychiatry | year= 2007 | volume= 78 | issue= 7 | pages= 732 | pmid=17575018 | doi=10.1136/jnnp.2007.115956 | pmc=2117688 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17575018  }}</ref><ref name="pmid219559663">{{cite journal| author=McGillicuddy JE| title=Neonatal brachial plexus palsy - historical perspective. | journal=J Pediatr Rehabil Med | year= 2011 | volume= 4 | issue= 2 | pages= 99-101 | pmid=21955966 | doi=10.3233/PRM-2011-0161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21955966  }}</ref>
==Classification ==
There is no established system for the classification of [disease name].


OR
In 1985, [[Narakas]] made a classification for Erb's palsy grading the [[severity]] and determining the [[prognosis]].<ref name="pmid4018968">{{cite journal| author=Narakas AO| title=The treatment of brachial plexus injuries. | journal=Int Orthop | year= 1985 | volume= 9 | issue= 1 | pages= 29-36 | pmid=4018968 | doi=10.1007/BF00267034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4018968  }}</ref>


[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
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==Classification ==
OR
Erb's palsy may be classified according to the severity of damage produced to the brachial plexus nerves as:
 
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3]. [Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
 
OR
 
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.


OR
# '''[[Neurapraxia]]''': Mild, temporal disruption, or [[compression]] of the [[myelin sheath]], with no structural damage to the [[axon]].<ref name="pmid238957135">{{cite journal| author=Menorca RM, Fussell TS, Elfar JC| title=Nerve physiology: mechanisms of injury and recovery. | journal=Hand Clin | year= 2013 | volume= 29 | issue= 3 | pages= 317-30 | pmid=23895713 | doi=10.1016/j.hcl.2013.04.002 | pmc=4408553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23895713  }}</ref>
# '''[[Axonotmesis]]''': Anatomic interruption of the [[myelin sheath]] and the [[axon]] of the nerve, but [[perineurium]] and [[epineurium]] remain intact.<ref name="pmid2389571333">{{cite journal| author=Menorca RM, Fussell TS, Elfar JC| title=Nerve physiology: mechanisms of injury and recovery. | journal=Hand Clin | year= 2013 | volume= 29 | issue= 3 | pages= 317-30 | pmid=23895713 | doi=10.1016/j.hcl.2013.04.002 | pmc=4408553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23895713  }}</ref>
#'''[[Neurotmesis]]''': Complete tear of the nerve, including the [[axon]] with his [[endoneurium]], [[perineurium]], and [[epineurium]].<ref name="pmid2389571343">{{cite journal| author=Menorca RM, Fussell TS, Elfar JC| title=Nerve physiology: mechanisms of injury and recovery. | journal=Hand Clin | year= 2013 | volume= 29 | issue= 3 | pages= 317-30 | pmid=23895713 | doi=10.1016/j.hcl.2013.04.002 | pmc=4408553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23895713  }}</ref>


If the staging system involves specific and characteristic findings and features: According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
Erb's palsy, in turn, is also classified within the Narakas system, which categorizes [[Brachial Plexus Birth Palsy]] (BPBP) according to the roots involved, and its directly linked to its prognosis:<ref name="pmid1978640733">{{cite journal| author=Al-Qattan MM, El-Sayed AA, Al-Zahrani AY, Al-Mutairi SA, Al-Harbi MS, Al-Mutairi AM | display-authors=etal| title=Narakas classification of obstetric brachial plexus palsy revisited. | journal=J Hand Surg Eur Vol | year= 2009 | volume= 34 | issue= 6 | pages= 788-91 | pmid=19786407 | doi=10.1177/1753193409348185 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19786407  }}</ref>


OR
* '''''Group I''':'' Classic Erb's palsy (C5-C6 roots). Good spontaneous recovery in > 80% of cases.<ref name="pmidhttps://doi.org/10.1016/B0-323-03386-5/X5001-26">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B0-323-03386-5/X5001-2 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmid25840493">{{cite journal| author=Duff SV, DeMatteo C| title=Clinical assessment of the infant and child following perinatal brachial plexus injury. | journal=J Hand Ther | year= 2015 | volume= 28 | issue= 2 | pages= 126-33; quiz 134 | pmid=25840493 | doi=10.1016/j.jht.2015.01.001 | pmc=4425986 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840493  }}</ref>
* '''''Group II''':'' Extended Erb's palsy (C5-C7 roots). Good spontaneous recovery in > 60% of cases.<ref name="pmidhttps://doi.org/10.1016/B0-323-03386-5/X5001-223">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B0-323-03386-5/X5001-2 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmid258404932">{{cite journal| author=Duff SV, DeMatteo C| title=Clinical assessment of the infant and child following perinatal brachial plexus injury. | journal=J Hand Ther | year= 2015 | volume= 28 | issue= 2 | pages= 126-33; quiz 134 | pmid=25840493 | doi=10.1016/j.jht.2015.01.001 | pmc=4425986 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840493  }}</ref>
* '''''Group III''':'' Global palsy without Horner syndrome (C5-C8 roots). Good spontaneous recovery of [[shoulder]]/[[Elbow-joint|elbow]] in > 30–50% of cases. Functional [[hand]] frequently noted.<ref name="pmidhttps://doi.org/10.1016/B0-323-03386-5/X5001-233">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B0-323-03386-5/X5001-2 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmid258404934">{{cite journal| author=Duff SV, DeMatteo C| title=Clinical assessment of the infant and child following perinatal brachial plexus injury. | journal=J Hand Ther | year= 2015 | volume= 28 | issue= 2 | pages= 126-33; quiz 134 | pmid=25840493 | doi=10.1016/j.jht.2015.01.001 | pmc=4425986 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840493  }}</ref>
* '''''Group IV''':'' Global [[palsy]] with [[Horner's syndrome|Horner syndrome]] (C5-T1). Without surgery, severe arm deficits are expected.<ref name="pmidhttps://doi.org/10.1016/B0-323-03386-5/X5001-243">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B0-323-03386-5/X5001-2 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmid258404933">{{cite journal| author=Duff SV, DeMatteo C| title=Clinical assessment of the infant and child following perinatal brachial plexus injury. | journal=J Hand Ther | year= 2015 | volume= 28 | issue= 2 | pages= 126-33; quiz 134 | pmid=25840493 | doi=10.1016/j.jht.2015.01.001 | pmc=4425986 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840493  }}</ref>


The staging of [malignancy name] is based on the [staging system].
OR
There is no established system for the staging of [malignancy name].
In the UK the primary classification system is the Narakas classification system (developed by A.O. Narakas in 1986).
==== The Narakas classification system                    <nowiki>https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/grades-of-erbs-palsy/</nowiki> ====
: ''Group I:'' The mildest clinical group, group I represents a classic Erb's palsy (C5-C6) with loss of shoulder abduction and external rotation, elbow flexion, and forearm supination. Wrist and digital movements are intact. Ninety percent of those in this group spontaneously recover fully. This is because the injury is not avulsion type and the target shoulder and elbow muscles are a shorter distance from the location of the injury.
; •
: ''Group II:'' This group includes C7 along with C5 and C6 involvement. Wrist and digital extension are absent. The prognosis is poorer with C5 to C7 injury because the target muscles are located farther from the site of the injury. Obstetric brachial plexus palsy most commonly involves the upper trunk (C5-C6) with or without injury to C7. Group I and II compose approximately 80% of obstetric brachial plexus palsy.
; •
: ''Group III:'' This group includes clients with flail extremity without Horner's syndrome. All roots of brachial plexus are injured without avulsion of nerve roots.
; •
: ''Group IV:'' This group includes clients with flail extremity and Horner's syndrome (drooping eye lids, myosis, enopthalmos, and anhydrosis). Prognosis is poor because the nerve roots are avulsed. The entire plexus (C5 to C7) is injured. Group III and IV constitute approximately 20% of the obstetric brachial plexus palsy. An isolated Klumpke's paralysis (C8-T1) is rare, and the target muscles in the hand are located farthest from the injury, and thus prognosis is poor.
<nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
'''Neurapraxia''': This is the mildest type of peripheral nerve damage when damage to the insulation around the nerve’s axon is damaged.
'''Axonotmesis''': This is more severe damage to the nerve fibres, where both the myelin sheath and the axon of the nerve are damaged but the Schwann cells and the connective tissue framework surrounding the axon (the endoneurium, perineurium and epineurium) remain intact.
'''Neurotmesis''': This is the most severe form of a nerve injury. Here the axon, myelin sheath and connective-tissue framework are damaged.
<nowiki>https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/grades-of-erbs-palsy/</nowiki>
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==Pathophysiology==
==Pathophysiology==
Erb's palsy is caused by stretching of the upper cervical roots C5–C7 during vaginal delivery.<ref name="pmid319332943">{{cite journal| author=Ivalde FC, Marazita-Valverde J, Bataglia D| title=Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement. | journal=J Ayub Med Coll Abbottabad | year= 2019 | volume= 28 | issue= 4 | pages= 479-480 | pmid=31933294 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31933294  }}</ref> waiter tip position Arm held limply adducted, internally rotated, and pronated with wrist flexed and fingers flexed (“waiter's tip” position)          <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
Erb's palsy is caused by damage to the [[upper brachial plexus]], [[cervical roots]] C5-C6,<ref name="pmid3193329422">{{cite journal| author=Ivalde FC, Marazita-Valverde J, Bataglia D| title=Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement. | journal=J Ayub Med Coll Abbottabad | year= 2019 | volume= 28 | issue= 4 | pages= 479-480 | pmid=31933294 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31933294  }}</ref> and in 50% of the cases, involving C7.<ref name="pmidhttps://doi.org/10.1016/C2009-0-55229-442">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2009-0-55229-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmidhttps://doi.org/10.1016/C2010-0-68825-04">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2010-0-68825-0 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> Although, damage can occur at any time, this usually happens during a delivery complicated by [[shoulder dystocia]].<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/20|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref> Excessive upper traction to the baby's head in opposite direction from the shoulder produces stretching to the nerve fibers that can lead to a simple temporal disruption or compression, to a complete tear of the entire [[plexus]].<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/20|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref> Another way of damage to upper brachial [[plexus]] can be made by excessive pressure on the baby's raised arm during a breech delivery. <ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/20|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref>


The most common cause of Erb's palsy is excessive lateral traction or stretching of the baby's head and neck in opposite directions during delivery usually associated with shoulder dystocia. This may happen during delivery of the head, the head may be deviated away from the axial plane. There can also be compression of the brachial plexus causing it to stretch and tear. Sometimes, pulling on the infant's shoulder during delivery or excessive pressure on the baby's raised arm during a breech delivery can cause brachial plexus injury. Two potential forces act on the brachial plexus during labor- natural expulsive force of the uterus, traction force applied by the obstetrician.      <nowiki>https://www.physio-pedia.com/Erb%27s_Palsy</nowiki>
The superior trunk of the brachial plexus has a motor and sensory fibers. Palsy of C5 and C6 roots affects the movement of [[deltoid]], [[biceps]], [[Brachialis muscle|brachialis]], [[Infraspinatus muscle|infraspinatus]], [[Supraspinatus muscle|supraspinatus]], and [[Serratus anterior muscle|serratus anterior]] muscles, as well as the sensation of the skin of the shoulder, anterolateral forearm, index and thumb fingers.<ref name="pmidhttps://doi.org/10.1016/C2010-0-68825-022">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2010-0-68825-0 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> Consequently, the patient is unable to [[abduct]] or externally rotate the shoulder, as well as supinate the forearm because of [[Muscle weakness|weakness]].<ref name="pmidhttps://doi.org/10.1016/C2010-0-68825-032">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2010-0-68825-0 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref>
 
Palsy of C5 and C6 affects the strength of deltoid, biceps, brachialis, infraspinatus, supraspinatus, and serratus anterior muscles. Also involved are the rhomboids, levator scapulae, and supinator muscles.       <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
 
In 50% of cases, C7 is affected            <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
 
The patient is unable to abduct or externally rotate the shoulder. The patient cannot supinate the forearm because of weakness of the supinator muscle. Sensory involvement is usually confined along the deltoid muscle and the distribution of the musculocutaneous nerve.               <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>


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==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
The most common cause of Erb's palsy is a difficult extraction during [[vaginal delivery]] due to [[shoulder dystocia]]. To review the risk factors that aim into a difficult extraction, and ultimately promote Erb's palsy, click here.


OR
In adults, the most frequent causes are [[Motor vehicle accident|motor vehicle accidents]] (>90% of cases), work-related trauma (industry), severe fall with stretching of the neck, assault (knife or bullet injury), and [[Iatrogenesis|iatrogenic]] injury (surgery).<ref name="pmid23661959">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959  }}</ref><br />
==Differentiating Erb's palsy from other Diseases==
Erb's palsy must be differentiated from:


Common causes of [disease] include [cause1], [cause2], and [cause3].
* Klumpke palsy. Presents with "claw hand" and negative grasp reflex, many times accompanied by Horner's syndrome.<ref name="pmid300206329">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>


OR
* Clavicular fracture.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/2020|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref><ref name="pmid93968892">{{cite journal| author=Peleg D, Hasnin J, Shalev E| title=Fractured clavicle and Erb's palsy unrelated to birth trauma. | journal=Am J Obstet Gynecol | year= 1997 | volume= 177 | issue= 5 | pages= 1038-40 | pmid=9396889 | doi=10.1016/s0002-9378(97)70010-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9396889  }}</ref> Presents with visible swelling, and deformity in the clavicular region, as well as crepitation and a positive "piano key sign".
* Osteomyelitis of the humerus or clavicle.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/2020|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref> Presents with high WB cell count, and osteolysis on plain radiograph.<ref name="pmid26981238">{{cite journal| author=Thaddeus Chika A, Emeka OM| title=Whole clavicle sequestration from chronic osteomyelitis in a 10 year old boy: A case report and review of the literature. | journal=Ann Med Surg (Lond) | year= 2016 | volume= 6 | issue=  | pages= 92-5 | pmid=26981238 | doi=10.1016/j.amsu.2016.02.011 | pmc=4777983 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26981238  }}</ref>
* Septic arthritis of the shoulder.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|date=|access-date=05/13/2020|website=Physiopedia|last=|first=|archive-url=|archive-date=|dead-url=}}</ref><ref name="pmid85506662">{{cite journal| author=Gabriel SR, Thometz JG, Jaradeh S| title=Septic arthritis associated with brachial plexus neuropathy. A case report. | journal=J Bone Joint Surg Am | year= 1996 | volume= 78 | issue= 1 | pages= 103-5 | pmid=8550666 | doi=10.2106/00004623-199601000-00014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8550666  }}</ref><ref name="pmid109652682">{{cite journal| author=Sharma RR, Sethu AU, Mahapatra AK, Pawar SJ, Nath A| title=Neonatal cervical osteomyelitis with paraspinal abscess and Erb's palsy. A case report and brief review of the literature. | journal=Pediatr Neurosurg | year= 2000 | volume= 32 | issue= 5 | pages= 230-3 | pmid=10965268 | doi=10.1159/000028943 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10965268  }}</ref> Presents with soft tissue edema of the shoulder in an MRI.<ref name="pmid85506662" />
*Spinal cord or brachial plexus tumor.<ref>{{Cite web|url=https://bestpractice.bmj.com/topics/en-us/746|title=Erb palsy differentials|last=Adamczyk|first=Mark J.|date=June 2018|website=BMJ Best Practice|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref> Presents with a bulging mass in the shoulder, and many times, is associated with neurofibromatosis type II.<ref name="pmid12523117">{{cite journal| author=Jarmundowicz W, Jabłoński P, Załuski R| title=[Brachial plexus tumors--neurosurgical treatment]. | journal=Neurol Neurochir Pol | year= 2002 | volume= 36 | issue= 5 | pages= 925-35 | pmid=12523117 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12523117  }}</ref>


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
<br />
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].<br />
==Differentiating Erb's palsy from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].<br />
==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of Erb's palsy is approximately 0.4 to 4 per 100,000 in the United States, and higher in other countries.<ref name="pmid319332942">{{cite journal| author=Ivalde FC, Marazita-Valverde J, Bataglia D| title=Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement. | journal=J Ayub Med Coll Abbottabad | year= 2019 | volume= 28 | issue= 4 | pages= 479-480 | pmid=31933294 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31933294  }}</ref>


0.5 to 5 infants per 1000 live births as a result of birth trauma.                     <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
*The [[prevalence]] of Erb's palsy is approximately 90 to 206 per 100,000 in the United States,<ref name="pmid300206328">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref> while [[prevalence]] worldwide is approximately 50 to 500 per 100,000 individuals.<ref name="pmidhttps://doi.org/10.1016/C2009-0-55229-433">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2009-0-55229-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref>
*An [[incidence]] of 36-45 per 100,000 births has been reported for Erb's palsy in the US.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|last=|first=|date=|website=Physiopedia|archive-url=|archive-date=|dead-url=|access-date=05/13/2020}}</ref><ref name="pmid10214829">{{cite journal| author=Gilbert WM, Nesbitt TS, Danielsen B| title=Associated factors in 1611 cases of brachial plexus injury. | journal=Obstet Gynecol | year= 1999 | volume= 93 | issue= 4 | pages= 536-40 | pmid=10214829 | doi=10.1016/s0029-7844(98)00484-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10214829  }}</ref>
*There is a greater [[prevalence]] of right arm Erb's palsy over the left side, with a rate of 1.3:1 to 7:1,<ref name="pmid313123232">{{cite journal| author=Yarfi C, Elekusi C, Banson AN, Angmorterh SK, Kortei NK, Ofori EK| title=Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study. | journal=Pan Afr Med J | year= 2019 | volume= 32 | issue=  | pages= 211 | pmid=31312323 | doi=10.11604/pamj.2019.32.211.17914 | pmc=6620083 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31312323  }}</ref><ref name="pmidhttps://doi.org/10.1016/B978-0-7216-1489-2.X1000-43">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B978-0-7216-1489-2.X1000-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> with only 3% affecting both arms.<ref name="pmidhttps://doi.org/10.1016/B978-0-7216-1489-2.X1000-42">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B978-0-7216-1489-2.X1000-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref>
*Permanent [[Disability|impairment]] occurs at a rate of 3-25% of patients with Erb's palsy.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's palsy|last=|first=|date=|website=Physiopedia|archive-url=|archive-date=|dead-url=|access-date=05/13/2020}}</ref>
*In 2007, a study made by [[Weizsaeker]] et al found that African descendants had an independently higher risk for Erb's palsy.<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|last=|first=|date=|website=Physiopedia|archive-url=|archive-date=|dead-url=|access-date=05/13/2020}}</ref><ref name="pmid17565612">{{cite journal| author=Weizsaecker K, Deaver JE, Cohen WR| title=Labour characteristics and neonatal Erb's palsy. | journal=BJOG | year= 2007 | volume= 114 | issue= 8 | pages= 1003-9 | pmid=17565612 | doi=10.1111/j.1471-0528.2007.01392.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17565612  }}</ref>
*Mothers age greater than 34 years old, were found to be more prone to have a child with Erb´s palsy.<ref name="pmid313123233">{{cite journal| author=Yarfi C, Elekusi C, Banson AN, Angmorterh SK, Kortei NK, Ofori EK| title=Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study. | journal=Pan Afr Med J | year= 2019 | volume= 32 | issue=  | pages= 211 | pmid=31312323 | doi=10.11604/pamj.2019.32.211.17914 | pmc=6620083 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31312323  }}</ref>
*Females seem to be slightly more affected by Erb's palsy in brachial plexus birth palsies than males,<ref name="pmid31312323">{{cite journal| author=Yarfi C, Elekusi C, Banson AN, Angmorterh SK, Kortei NK, Ofori EK| title=Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study. | journal=Pan Afr Med J | year= 2019 | volume= 32 | issue=  | pages= 211 | pmid=31312323 | doi=10.11604/pamj.2019.32.211.17914 | pmc=6620083 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31312323  }}</ref> while this proportion greatly inverts in adulthood, with more accidents occurring in males.<br />


OR
==Risk Factors==
Common risk factors for neonatal Erb's palsy involve maternal, fetal, and labor factors:


In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
1. Mothers risks:


OR
* Maternal [[diabetes]]<ref name="pmid248630286">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>
*Maternal obesity
*[[Shoulder dystocia]] in prior [[deliveries]]


In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
2. Fetal risks:


Patients of all age groups may develop [disease name].
*[[Breech birth|Breech]] presentation<ref name="pmid19680484">{{cite journal| author=Chater M, Camfield P, Camfield C| title=Erb's palsy - Who is to blame and what will happen? | journal=Paediatr Child Health | year= 2004 | volume= 9 | issue= 8 | pages= 556-560 | pmid=19680484 | doi=10.1093/pch/9.8.556 | pmc=2724163 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19680484  }}</ref>
*[[Macrosomia]]<ref name="pmid248630284">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>


OR
3. Labor risks:


The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
*[[Shoulder dystocia]]<ref name="pmid248630282">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>
*[[Oxytocin]] use<ref name="pmid24863028">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>


OR
*[[Prolonged labor]] (second stage of labor > 60 minutes)<ref>{{Cite web|url=https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/|title=What factors are associated with brachial plexus injury during childbirth?|last=|first=|date=|website=Royds Withy King|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref>
* Difficult extractions (need for [[forceps]] or other operative measures)<ref>{{Cite web|url=https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/|title=What factors are associated with brachial plexus injury during childbirth?|last=|first=|date=|website=Royds Withy King|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref>


[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
Studies have shown that these typical risk factors are not reliable predictors for Erb's palsy.<ref name="pmid248630287">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref> Furthermore, the majority of Erb's palsy newborns have come from mothers with no risk factors, and even [[C-section]] does not eliminate the risk for neonatal Erb's palsy.<ref name="pmid248630283">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref><ref name="pmid248630288">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>


OR
Interestingly, a higher rate of [[clavicular fractures]] have not shown an association with BPBP,<ref name="pmid306851363">{{cite journal| author=Gandhi RA, DeFrancesco CJ, Shah AS| title=The Association of Clavicle Fracture With Brachial Plexus Birth Palsy. | journal=J Hand Surg Am | year= 2019 | volume= 44 | issue= 6 | pages= 467-472 | pmid=30685136 | doi=10.1016/j.jhsa.2018.11.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30685136  }}</ref> but a notable association was found between BPBP and fracture of the middle third of the [[clavicle]].<ref name="pmid319854763">{{cite journal| author=Asena M, Akelma H, Ziyadanoğulları MO| title=The relationship between the location of neonatal clavicular fractures and predisposing factors. | journal=J Neonatal Perinatal Med | year= 2020 | volume=  | issue=  | pages=  | pmid=31985476 | doi=10.3233/NPM-190321 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31985476  }}</ref>


[Chronic disease name] is usually first diagnosed among [age group].
<br />
==Screening==
As mentioned previously, the majority of Erb's palsy cases appear in children of mothers with no risk factors, for this reason, the condition is impossible to predict and becomes a challenge for the entire team to reduce this risk to the minimum. However, prenatal care can help us know when a vaginal delivery may be complicated:


OR
*[[Pelvis|Pelvic]] measurements. Will inform us if the maternal pelvis is narrow and its form (gynaecoid, anthropoid, platypelloid, android), which could complicate  delivery.


[Acute disease name] commonly affects [age group].
* Serum glucose measurements. Will inform us of maternal diabetes, which is directly associated with macrosomic children.


There is no racial predilection to [disease name].
*[[Prenatal]] ultrasound. Will inform us of the fetal presentation and the approximate fetal weight.


OR
Once the child is delivered, several findings that can make us suspect an Erb's palsy:


[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
* Negative ipsilateral [[Moro reflex]], and positive palmar [[grasp reflex]].
*[[Muscle]] tone and [[movement scale]].


[Disease name] affects men and women equally.
<br />
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].<br />
==Risk Factors==
Common risk factors in the development of Erb's palsy include:
 
* Maternal gestational diabetes
*Maternal obesity
* Shoulder dystocia
* Macrosomia
*Prolonged labor .Duration of second stage of labor(over 60 minutes) <nowiki>https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/</nowiki>
*Breech presentation
* Difficult extractions (need of forceps or other operative measures)
 
* Shoulder dystocia in prior deliveries            <nowiki>https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/</nowiki>
 
Although, these are classic risk factors, studies have shown that they are not relieble predictors, and even C-sections does not exclude the possibility of these events. Furthormore he majority Erb's palsy cases have comed from mothers with no risk factors, delivering neonates with birth weight greater than 4,500g. Furthermore, cesarean section reduces but does not completely eliminate the risk for NBPP.<ref name="pmid24863028">{{cite journal| author=Ouzounian JG| title=Risk factors for neonatal brachial plexus palsy. | journal=Semin Perinatol | year= 2014 | volume= 38 | issue= 4 | pages= 219-21 | pmid=24863028 | doi=10.1053/j.semperi.2014.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24863028  }}</ref>
 
Historically, Erb's palsy was associated with clavicule fractures in newborns with shoulder dystocia, however BPBP has been found to be present in a near rate of infants with shoulder distocia independently if clavicule fracture exists, in most of the cases. fracture.<ref name="pmid30685136">{{cite journal| author=Gandhi RA, DeFrancesco CJ, Shah AS| title=The Association of Clavicle Fracture With Brachial Plexus Birth Palsy. | journal=J Hand Surg Am | year= 2019 | volume= 44 | issue= 6 | pages= 467-472 | pmid=30685136 | doi=10.1016/j.jhsa.2018.11.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30685136  }}</ref> Interestingly, a notable association was found between BPBP and fracture of the middle third of the clavicule.<ref name="pmid31985476">{{cite journal| author=Asena M, Akelma H, Ziyadanoğulları MO| title=The relationship between the location of neonatal clavicular fractures and predisposing factors. | journal=J Neonatal Perinatal Med | year= 2020 | volume=  | issue=  | pages=  | pmid=31985476 | doi=10.3233/NPM-190321 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31985476  }}</ref><br />
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
 
OR
 
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].<br />
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
Prognosis is generally good; If left untreated, <25% of neonates Erb's palsy may progress to develop permanent disability and impairment, while the rest will recover spontaneously after a month,<ref name="pmidhttps://doi.org/10.1016/C2015-0-00649-923">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2015-0-00649-9 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> depending on the [[severity]] of the [[Injury Severity Score|injury]] (close to 100% of [[Neuropraxia|neuropraxias]]).


Although 75% of brachial plexus injuries resolve spontaneously and completely within the first month after birth, 25% result in permanent disability and impairment.               <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
[[Denervated muscles|Denervated]] muscles become irreversibly injured after 18 to 24 months, and these time-sensitive changes become the basis for early management.<ref name="pmid3002063263">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>


OR
Several scales have been developed to predict the prognosis in Erb's palsy: [[Toronto test|Toronto test score]], active movement scale, [[mallet scale]], and [[Toddler Arm Use Test]]<ref>{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|last=|first=|date=|website=Physiopedia|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref>   


Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
Common long term complications of Erb's palsy include:


OR
* Reduced strength and stamina<ref name="pmid300206327">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Irregular [[Joint|joints]] function<ref name="pmid300206326">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Muscular [[atrophy]]<ref name="pmid300206325">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Abnormal bone growth<ref name="pmid300206324">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
*[[Osteoarthritis]]<ref name="pmid300206323">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
*[[Limb length discrepancy]]<ref name="pmid300206322">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Impaired [[Balance disorder|balance]], and [[Motor coordination|coordination]]<ref name="pmid30020632">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>  <br />


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
* Toronto test score
* Active movement scale
* Mallet scale
* Toddler Arm Use Test    <nowiki>https://www.physio-pedia.com/Erb%27s_Palsy</nowiki>
<br />
==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
The diagnosis of Erb's palsy is made clinically, but several studies may help to confirm it or rule out other conditions, such as [[Ultrasound guidance|ultrasound]], [[MRI]], [[Electromyography|electromyography (EMG)]], [[X ray|x-rays]], and [[Computed tomography|CT]].<ref name="pmid3002063210">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
 
=== History ===
OR
The classic history of a newborn with Erb's palsy is a macrosomic baby born from a diabetic mother with prolonged vaginal delivery, which presents with shoulder dystocia.
 
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].
 
=== History and Symptoms ===
The majority of patients with [disease name] are asymptomatic.
 
OR
 
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
 
=== Physical Examination ===
=== Physical Examination ===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with Erb's palsy usually appear on physical examination with the affected arm held limply [[Adduction|adducted]], internally rotated, and pronated with an outward direction of the palm, wrist flexed and clung fingers (“waiter's tip” position).<ref name="pmidhttps://doi.org/10.1016/C2009-0-55229-45">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2009-0-55229-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> The patient is unable to [[Abduction|abduct]] or externally rotate the shoulder. Sensory involvement is usually confined to the shoulder and along the distribution of the musculocutaneous nerve.<ref name="pmidhttps://doi.org/10.1016/C2009-0-60140-93">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2009-0-60140-9 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> Biceps, brachioradialis, and Moro reflexes are absent with hand movement and palmar grasp present (differentiating factor from Klumpke palsy).<ref name="pmidhttps://doi.org/10.1016/B978-0-7216-1489-2.X1000-4">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B978-0-7216-1489-2.X1000-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref>  The sensation is impaired in the skin of the shoulder, anterolateral forearm, index and thumb fingers.<ref name="pmidhttps://doi.org/10.1016/C2010-0-68825-022" />  Ocassionaly, there can be phrenic nerve palsy leading to [[Thoracic diaphragm|hemidiaphragmatic]] [[paralysis]].<ref name="pmidhttps://doi.org/10.1016/B978-0-7216-1489-2.X1000-44">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/B978-0-7216-1489-2.X1000-4 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref><ref name="pmid3002063211">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>  
 
Biceps reflex absent, Moro reflex with hand movement but no shoulder abduction, palmar grasp present           <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
 
OR


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
In prolonged Erb's palsies, atrophy of the deltoid, biceps, and brachialis muscles can be observed.<ref name="pmid3002063212">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>


OR
=== Ultrasound ===
 
Ultrasound is many times the initial study when there is a suspected glenohumeral dysplasia.<ref name="pmid256157816">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref> The advantages of this study is that it doesn't produce any ionizing radiation, and can be performed without sedation.<ref name="pmid256157815">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref>
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
=== Laboratory Findings ===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
 
OR
 
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
 
OR
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].
 
=== Electrocardiogram ===
There are no ECG findings associated with [disease name].
 
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


=== Electrophysiology/EMG ===
[[Electrophysiology]] studies are probably the single most important imaging study for Erb's palsy, and an important tool when making surgical and therapeutic decisions.<ref name="pmid236619596" /> [[Electromyography|EMG]] can detect the presence of fibrillation potentials indicate denervation.<ref name=":0" /> Among the applications for these kinds of studies are that they help categorize the localization, extent, and the type of lesion ([[Preganglionic fibers|preganglionic]]/ [[Postganglionic fibers|postganglionic]]), postoperative monitoring, the status of individual muscles ([[denervated]], [[reinnervating]], etc), and can give you a compound [[motor action potential]] (CMAP) diagnosis that will dictate the need of surgery in crucial period, before 3 months of age.<ref name="pmid236619596">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959  }}</ref><ref name="pmid16000255">{{cite journal| author=Pitt M, Vredeveld JW| title=The role of electromyography in the management of the brachial plexus palsy of the newborn. | journal=Clin Neurophysiol | year= 2005 | volume= 116 | issue= 8 | pages= 1756-61 | pmid=16000255 | doi=10.1016/j.clinph.2005.04.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16000255  }}</ref> [[Electromyography|EMG]] fails to describe the etiology and prognosis of Erb's palsy, but when used early, can distinguish between intrauterine cases of palsy from those aquiered during [[Childbirth|delivery]].<ref name="pmid160002552">{{cite journal| author=Pitt M, Vredeveld JW| title=The role of electromyography in the management of the brachial plexus palsy of the newborn. | journal=Clin Neurophysiol | year= 2005 | volume= 116 | issue= 8 | pages= 1756-61 | pmid=16000255 | doi=10.1016/j.clinph.2005.04.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16000255  }}</ref>
=== X-ray ===
=== X-ray ===
There are no x-ray findings associated with [disease name].
Help to rule out shoulder [[Joint dislocation|dislocations]], clavicular, humeral, and rib fractures, as well as accesory cervical ribs, and raised diaphragm (phrenic nerve injury).<ref name="pmid3002063213">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue= | pages= | pmid=30020632 | doi= | pmc= | url= }}</ref><ref name="pmid236619596" />
 
OR
 
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
=== Echocardiography or Ultrasound ===
There are no echocardiography/ultrasound findings associated with [disease name].
 
OR
 
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


=== CT scan ===
=== CT scan ===
There are no CT scan findings associated with [disease name].
[[Computed tomography|CT]], in addition to evaluating bone features with greater precision than X-rays, may detect pseudomeningoceles, which could be a sign of nerve root avulsions,<ref name="pmid17987326">{{cite journal| author=Tanaka M, Ikuma H, Nakanishi K, Sugimoto Y, Misawa H, Takigawa T | display-authors=etal| title=Spinal cord herniation into pseudomeningocele after traumatic nerve root avulsion: case report and review of the literature. | journal=Eur Spine J | year= 2008 | volume= 17 Suppl 2 | issue=  | pages= S263-6 | pmid=17987326 | doi=10.1007/s00586-007-0537-1 | pmc=2525919 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17987326  }}</ref><ref name=":0">{{Cite web|url=https://www.physio-pedia.com/Erb%27s_Palsy|title=Erb's Palsy|last=|first=|date=|website=Physiopedia|archive-url=|archive-date=|dead-url=|access-date=05/15/2020}}</ref><ref name="pmid256157812">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref> also evaluates the status of the nerve elements when an exploration or reconstructive surgery is planned.<ref name="pmid25615781">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref>


OR
CT myelography used to be the gold standard for evaluation of nerve roots avulsion in adults but now is rarely used;<ref name="pmid236619596" /> It utilizes intrathecal injection of water-soluble iodinated contrast material.<ref name="pmid256157814">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref>
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


=== MRI ===
=== MRI ===
There are no MRI findings associated with [disease name].
MRI can detect the same findings as CT scans, with greater sensitivity for soft tissues.


OR
MR myelography is also used in the evaluation of Erb's palsy, but unlike [[Myelography|CT myelography]], it doesn't need constrast material, instead, uses the intrinsic contrast generated between the nerve roots and the surrounding [[CSF]].<ref name="pmid256157813">{{cite journal| author=Menashe SJ, Tse R, Nixon JN, Ishak GE, Thapa MM, McBroom JA | display-authors=etal| title=Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. | journal=AJR Am J Roentgenol | year= 2015 | volume= 204 | issue= 2 | pages= W199-206 | pmid=25615781 | doi=10.2214/AJR.14.12862 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25615781  }}</ref>
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
=== Other Imaging Findings ===
There are no other imaging findings associated with [disease name].
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
=== Other Diagnostic Studies ===
There are no other diagnostic studies associated with [disease name].
 
OR
 
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].<br />
 
* X-rays of the chest - to rule out clavicular or humeral fracture
 
* MRI of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
 
* CT Scan of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
 
* EMG/Nerve conduction studies- presence of fibrillation potentials indicate denervation
* <nowiki>https://www.physio-pedia.com/Erb%27s_Palsy</nowiki>


<br />
<br />


==Treatment==
==Treatment==
=== Medical Therapy ===
=== Medical Therapy ===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
There is no consensus on the appropriate treatment for Erb's palsy since this will depend on the severity of the affection, age of the patient, and [[prognosis]].<ref name="pmid196804842">{{cite journal| author=Chater M, Camfield P, Camfield C| title=Erb's palsy - Who is to blame and what will happen? | journal=Paediatr Child Health | year= 2004 | volume= 9 | issue= 8 | pages= 556-560 | pmid=19680484 | doi=10.1093/pch/9.8.556 | pmc=2724163 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19680484  }}</ref> Treatment is often multidisciplinary and aimed to be as conservative as possible.<ref name="pmid106767732">{{cite journal| author=Dodds SD, Wolfe SW| title=Perinatal brachial plexus palsy. | journal=Curr Opin Pediatr | year= 2000 | volume= 12 | issue= 1 | pages= 40-7 | pmid=10676773 | doi=10.1097/00008480-200002000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10676773  }}</ref>


OR
* Immobilization and splinting. It is commonly used during the first week from injury to avoid flexion contractures.<ref name="pmid196804844">{{cite journal| author=Chater M, Camfield P, Camfield C| title=Erb's palsy - Who is to blame and what will happen? | journal=Paediatr Child Health | year= 2004 | volume= 9 | issue= 8 | pages= 556-560 | pmid=19680484 | doi=10.1093/pch/9.8.556 | pmc=2724163 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19680484  }}</ref>
*[[Electrostimulation]]. Its use is still controversial.<ref name="pmid196804843">{{cite journal| author=Chater M, Camfield P, Camfield C| title=Erb's palsy - Who is to blame and what will happen? | journal=Paediatr Child Health | year= 2004 | volume= 9 | issue= 8 | pages= 556-560 | pmid=19680484 | doi=10.1093/pch/9.8.556 | pmc=2724163 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19680484  }}</ref>
*[[Hydrotherapy]]. It is a useful method of physical therapy, due to its anti-gravity properties, facilitates muscle relaxation, and range of motion; at the same time, it increases strength and muscle build-up due to water resistance.<ref name="pmid3002063253">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Physiotherapy: It can be done in combination with hydrotherapy or alone. Consist of passive and active range of motion, strengthening, and stretching exercises.<ref name="pmid3002063243">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
* Occupational therapy. It is usually required for adult patients with long-term damage to help them deal with daily-living activities (eating, tying shoes, playing, drawing).<ref name="pmid3002063233">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
=== Surgery ===
 
Surgery is not the first-line treatment option for patients with Erb's palsy. Surgery is usually reserved for patients with no functional recovery from physical therapy and will depend on the time from damage, the [[cervical roots]] involved, and the patient’s age.<ref name="pmid319332944">{{cite journal| author=Ivalde FC, Marazita-Valverde J, Bataglia D| title=Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement. | journal=J Ayub Med Coll Abbottabad | year= 2019 | volume= 28 | issue= 4 | pages= 479-480 | pmid=31933294 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31933294  }}</ref>
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR


Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
In infants, surgical intervention is indicated if the motor function does not improve after 3 months of age.<ref name="pmidhttps://doi.org/10.1016/C2015-0-00649-94">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/C2015-0-00649-9 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> After 20 to 24 months of denervation, exists a loss of [[Endplates|neuro-muscular endplates]], which makes the timing for surgery a crucial point.<ref name="pmid236619594">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959  }}</ref>


OR
Surgical intervention includes nerve decompression, [[nerve]] repairs, and graft implantation, with great chances of success.<ref name="pmid3002063223">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>


Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
One of the surgical procedures done for persistent cases is Hoffer-procedure, which has been shown to improve functional outcomes when operated before age 2.5 years.<ref name="pmid320094233">{{cite journal| author=Alluri RK, Lightdale-Miric N, Meisel E, Kim G, Kaplan J, Bougioukli S | display-authors=etal| title=Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique. | journal=Bone Joint J | year= 2020 | volume= 102-B | issue= 2 | pages= 246-253 | pmid=32009423 | doi=10.1302/0301-620X.102B2.BJJ-2019-0999.R1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32009423  }}</ref>


OR
Secondary reconstruction procedures have been realized in patients as a last resource to gain partial functionality.<ref name="pmid106767735">{{cite journal| author=Dodds SD, Wolfe SW| title=Perinatal brachial plexus palsy. | journal=Curr Opin Pediatr | year= 2000 | volume= 12 | issue= 1 | pages= 40-7 | pmid=10676773 | doi=10.1097/00008480-200002000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10676773  }}</ref> These include:


Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*[[Pectoralis major muscle|Pectoralis major]] release to improve passive range of motion<ref name="pmid106767734">{{cite journal| author=Dodds SD, Wolfe SW| title=Perinatal brachial plexus palsy. | journal=Curr Opin Pediatr | year= 2000 | volume= 12 | issue= 1 | pages= 40-7 | pmid=10676773 | doi=10.1097/00008480-200002000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10676773  }}</ref>


OR
*[[Tendon]] transfers for decreased active external rotation<ref name="pmid236619597">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959  }}</ref>
 
*[[Trapezius muscle|Trapezius]] transfer to stabilise shoulder<ref name="pmid236619598">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959 }}</ref>
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
*Fractional release of the pronator teres and the lacertus [[fibrosis]] to improve passive [[supination]]<ref name="pmid106767733">{{cite journal| author=Dodds SD, Wolfe SW| title=Perinatal brachial plexus palsy. | journal=Curr Opin Pediatr | year= 2000 | volume= 12 | issue= 1 | pages= 40-7 | pmid=10676773 | doi=10.1097/00008480-200002000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10676773 }}</ref>
 
* Shoulder and wrist [[arthrodesis]] to improve posture<ref name="pmid236619595">{{cite journal| author=Thatte MR, Babhulkar S, Hiremath A| title=Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. | journal=Ann Indian Acad Neurol | year= 2013 | volume= 16 | issue= 1 | pages= 26-33 | pmid=23661959 | doi=10.4103/0972-2327.107686 | pmc=3644778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23661959  }}</ref>
=== Surgery ===
Surgery is not the first-line treatment option for patients with Erb's palsy. Surgery is usually reserved for patients depending on time and cervical roots involved and patient’s age.<ref name="pmid31933294">{{cite journal| author=Ivalde FC, Marazita-Valverde J, Bataglia D| title=Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement. | journal=J Ayub Med Coll Abbottabad | year= 2019 | volume= 28 | issue= 4 | pages= 479-480 | pmid=31933294 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31933294 }}</ref>
 
One of the surgical procedures done for persistent cases is Hoffer-procedure, wich has been shown to improve functional outcomes when operated before age 2.5 years.<ref name="pmid32009423">{{cite journal| author=Alluri RK, Lightdale-Miric N, Meisel E, Kim G, Kaplan J, Bougioukli S | display-authors=etal| title=Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique. | journal=Bone Joint J | year= 2020 | volume= 102-B | issue= 2 | pages= 246-253 | pmid=32009423 | doi=10.1302/0301-620X.102B2.BJJ-2019-0999.R1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32009423 }}</ref>
 
Surgical intervention is indicated if the motor function does not improve after 3 months of age. Surgical intervention is indicated if the motor function does not improve after 3 months of age. <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>


=== Primary Prevention ===
=== Primary Prevention ===
There are no established measures for the primary prevention of [disease name].
Effective measures for the primary prevention of Erb's palsy include prenatal screening to detect [[fetal]], or maternal risk factors, and close management of mothers with diabetes and obesity.
 
OR
 
There are no available vaccines against [disease name].
 
OR
 
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
 
=== Secondary Prevention ===
=== Secondary Prevention ===
There are no established measures for the secondary prevention of [disease name].
Effective measures for the secondary prevention of Erb's palsy include the application of shoulder dystocia maneuvers during labor (placement of mother in [[McRobert's]] position), and once detected a [[brachial plexus]] palsy, prompt medical or surgical management when necessary.


OR
=== Tertiary Prevention ===
Effective measures for the primary prevention of Erb's palsy aims to improve functionality in patients with brachial [[paralysis]] through [[physiotherapy]] and [[occupational therapy]].


Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
<br />
 
 
Placing the mother in the ‘McRoberts’ position. This is when she is placed on her back and her legs are removed from stirrups. Two people are required to flex each of the mother’s leg backwards at the same time towards the mother’s head to widen the pelvis.
 
'''3.''' If Step 2 is not effective, while still in the McRobert’s position, a third person should apply suprapubic pressure by pressing down just above the maternal pubic bone in an effort to encourage the fetal shoulder to descend down into the pelvis and under the bone. Gentle traction should be applied to deliver the baby.


<nowiki>https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/</nowiki><br />
==References==
==References==
{{reflist|2}}==References==
{{reflist|2}}==References== <nowiki>{{Reflist|2}}</nowiki>{{Certain conditions originating in the perinatal period}}
<nowiki>{{Reflist|2}}</nowiki>{{Certain conditions originating in the perinatal period}}


[[Category:Peripheral nervous system]]
[[Category:Peripheral nervous system]]

Revision as of 16:38, 21 May 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D., Fahime Shojaei, M.D.


Overview

Duchenne-Erb's palsy or simply Erb's palsy, is a lesion to the C5-C6 brachial roots; it can be a form of brachial plexus birth palsy (BPBP) or can be acquired in adulthood. It occurs when there is a stretching of the superior brachial plexus (neuropraxia, neuroma, neurotmesis), leading in most of the cases to a temporal weakness and loss of sensation in certain muscles of the upper extremity.

Historical Perspective

Erb's palsy, was first described by William Smellie, a British obstetrician, in 1754 on his midwifery book, "Traité de la theorie et pratique des accouchemens".[1]

In 1861, French neurologist, Guillaume Benjamin Amand Duchenne was the first to discover the association of paralysis in the same muscles (deltoid, biceps, and subscapularis) of arms and shoulders of infants delivered vaginally, naming it "obstetric palsy of the brachial plexus".[2][3]

In 1874, German neurologist, Wilhelm Heinrich Erb concluded that paralysis was associated with a radicular lesion at the level of the superior plexus, C5-C6, and not from isolated peripheral nerve lesions.[4][5]

In 1985, Narakas made a classification for Erb's palsy grading the severity and determining the prognosis.[6]


Classification

Erb's palsy may be classified according to the severity of damage produced to the brachial plexus nerves as:

  1. Neurapraxia: Mild, temporal disruption, or compression of the myelin sheath, with no structural damage to the axon.[7]
  2. Axonotmesis: Anatomic interruption of the myelin sheath and the axon of the nerve, but perineurium and epineurium remain intact.[8]
  3. Neurotmesis: Complete tear of the nerve, including the axon with his endoneurium, perineurium, and epineurium.[9]

Erb's palsy, in turn, is also classified within the Narakas system, which categorizes Brachial Plexus Birth Palsy (BPBP) according to the roots involved, and its directly linked to its prognosis:[10]

  • Group I: Classic Erb's palsy (C5-C6 roots). Good spontaneous recovery in > 80% of cases.[11][12]
  • Group II: Extended Erb's palsy (C5-C7 roots). Good spontaneous recovery in > 60% of cases.[13][14]
  • Group III: Global palsy without Horner syndrome (C5-C8 roots). Good spontaneous recovery of shoulder/elbow in > 30–50% of cases. Functional hand frequently noted.[15][16]
  • Group IV: Global palsy with Horner syndrome (C5-T1). Without surgery, severe arm deficits are expected.[17][18]


Pathophysiology

Erb's palsy is caused by damage to the upper brachial plexus, cervical roots C5-C6,[19] and in 50% of the cases, involving C7.[20][21] Although, damage can occur at any time, this usually happens during a delivery complicated by shoulder dystocia.[22] Excessive upper traction to the baby's head in opposite direction from the shoulder produces stretching to the nerve fibers that can lead to a simple temporal disruption or compression, to a complete tear of the entire plexus.[23] Another way of damage to upper brachial plexus can be made by excessive pressure on the baby's raised arm during a breech delivery. [24]

The superior trunk of the brachial plexus has a motor and sensory fibers. Palsy of C5 and C6 roots affects the movement of deltoid, biceps, brachialis, infraspinatus, supraspinatus, and serratus anterior muscles, as well as the sensation of the skin of the shoulder, anterolateral forearm, index and thumb fingers.[25] Consequently, the patient is unable to abduct or externally rotate the shoulder, as well as supinate the forearm because of weakness.[26]


Causes

The most common cause of Erb's palsy is a difficult extraction during vaginal delivery due to shoulder dystocia. To review the risk factors that aim into a difficult extraction, and ultimately promote Erb's palsy, click here.

In adults, the most frequent causes are motor vehicle accidents (>90% of cases), work-related trauma (industry), severe fall with stretching of the neck, assault (knife or bullet injury), and iatrogenic injury (surgery).[27]

Differentiating Erb's palsy from other Diseases

Erb's palsy must be differentiated from:

  • Klumpke palsy. Presents with "claw hand" and negative grasp reflex, many times accompanied by Horner's syndrome.[28]
  • Clavicular fracture.[29][30] Presents with visible swelling, and deformity in the clavicular region, as well as crepitation and a positive "piano key sign".
  • Osteomyelitis of the humerus or clavicle.[31] Presents with high WB cell count, and osteolysis on plain radiograph.[32]
  • Septic arthritis of the shoulder.[33][34][35] Presents with soft tissue edema of the shoulder in an MRI.[34]
  • Spinal cord or brachial plexus tumor.[36] Presents with a bulging mass in the shoulder, and many times, is associated with neurofibromatosis type II.[37]


Epidemiology and Demographics

  • The prevalence of Erb's palsy is approximately 90 to 206 per 100,000 in the United States,[38] while prevalence worldwide is approximately 50 to 500 per 100,000 individuals.[39]
  • An incidence of 36-45 per 100,000 births has been reported for Erb's palsy in the US.[40][41]
  • There is a greater prevalence of right arm Erb's palsy over the left side, with a rate of 1.3:1 to 7:1,[42][43] with only 3% affecting both arms.[44]
  • Permanent impairment occurs at a rate of 3-25% of patients with Erb's palsy.[45]
  • In 2007, a study made by Weizsaeker et al found that African descendants had an independently higher risk for Erb's palsy.[46][47]
  • Mothers age greater than 34 years old, were found to be more prone to have a child with Erb´s palsy.[48]
  • Females seem to be slightly more affected by Erb's palsy in brachial plexus birth palsies than males,[49] while this proportion greatly inverts in adulthood, with more accidents occurring in males.

Risk Factors

Common risk factors for neonatal Erb's palsy involve maternal, fetal, and labor factors:

1. Mothers risks:

2. Fetal risks:

3. Labor risks:

Studies have shown that these typical risk factors are not reliable predictors for Erb's palsy.[57] Furthermore, the majority of Erb's palsy newborns have come from mothers with no risk factors, and even C-section does not eliminate the risk for neonatal Erb's palsy.[58][59]

Interestingly, a higher rate of clavicular fractures have not shown an association with BPBP,[60] but a notable association was found between BPBP and fracture of the middle third of the clavicle.[61]


Screening

As mentioned previously, the majority of Erb's palsy cases appear in children of mothers with no risk factors, for this reason, the condition is impossible to predict and becomes a challenge for the entire team to reduce this risk to the minimum. However, prenatal care can help us know when a vaginal delivery may be complicated:

  • Pelvic measurements. Will inform us if the maternal pelvis is narrow and its form (gynaecoid, anthropoid, platypelloid, android), which could complicate delivery.
  • Serum glucose measurements. Will inform us of maternal diabetes, which is directly associated with macrosomic children.
  • Prenatal ultrasound. Will inform us of the fetal presentation and the approximate fetal weight.

Once the child is delivered, several findings that can make us suspect an Erb's palsy:


Natural History, Complications, and Prognosis

Prognosis is generally good; If left untreated, <25% of neonates Erb's palsy may progress to develop permanent disability and impairment, while the rest will recover spontaneously after a month,[62] depending on the severity of the injury (close to 100% of neuropraxias).

Denervated muscles become irreversibly injured after 18 to 24 months, and these time-sensitive changes become the basis for early management.[63]

Several scales have been developed to predict the prognosis in Erb's palsy: Toronto test score, active movement scale, mallet scale, and Toddler Arm Use Test[64]

Common long term complications of Erb's palsy include:

Diagnosis

Diagnostic Study of Choice

The diagnosis of Erb's palsy is made clinically, but several studies may help to confirm it or rule out other conditions, such as ultrasound, MRI, electromyography (EMG), x-rays, and CT.[72]

History

The classic history of a newborn with Erb's palsy is a macrosomic baby born from a diabetic mother with prolonged vaginal delivery, which presents with shoulder dystocia.

Physical Examination

Patients with Erb's palsy usually appear on physical examination with the affected arm held limply adducted, internally rotated, and pronated with an outward direction of the palm, wrist flexed and clung fingers (“waiter's tip” position).[73] The patient is unable to abduct or externally rotate the shoulder. Sensory involvement is usually confined to the shoulder and along the distribution of the musculocutaneous nerve.[74] Biceps, brachioradialis, and Moro reflexes are absent with hand movement and palmar grasp present (differentiating factor from Klumpke palsy).[75] The sensation is impaired in the skin of the shoulder, anterolateral forearm, index and thumb fingers.[25] Ocassionaly, there can be phrenic nerve palsy leading to hemidiaphragmatic paralysis.[76][77]

In prolonged Erb's palsies, atrophy of the deltoid, biceps, and brachialis muscles can be observed.[78]

Ultrasound

Ultrasound is many times the initial study when there is a suspected glenohumeral dysplasia.[79] The advantages of this study is that it doesn't produce any ionizing radiation, and can be performed without sedation.[80]

Electrophysiology/EMG

Electrophysiology studies are probably the single most important imaging study for Erb's palsy, and an important tool when making surgical and therapeutic decisions.[81] EMG can detect the presence of fibrillation potentials indicate denervation.[82] Among the applications for these kinds of studies are that they help categorize the localization, extent, and the type of lesion (preganglionic/ postganglionic), postoperative monitoring, the status of individual muscles (denervated, reinnervating, etc), and can give you a compound motor action potential (CMAP) diagnosis that will dictate the need of surgery in crucial period, before 3 months of age.[81][83] EMG fails to describe the etiology and prognosis of Erb's palsy, but when used early, can distinguish between intrauterine cases of palsy from those aquiered during delivery.[84]

X-ray

Help to rule out shoulder dislocations, clavicular, humeral, and rib fractures, as well as accesory cervical ribs, and raised diaphragm (phrenic nerve injury).[85][81]

CT scan

CT, in addition to evaluating bone features with greater precision than X-rays, may detect pseudomeningoceles, which could be a sign of nerve root avulsions,[86][82][87] also evaluates the status of the nerve elements when an exploration or reconstructive surgery is planned.[88]

CT myelography used to be the gold standard for evaluation of nerve roots avulsion in adults but now is rarely used;[81] It utilizes intrathecal injection of water-soluble iodinated contrast material.[89]

MRI

MRI can detect the same findings as CT scans, with greater sensitivity for soft tissues.

MR myelography is also used in the evaluation of Erb's palsy, but unlike CT myelography, it doesn't need constrast material, instead, uses the intrinsic contrast generated between the nerve roots and the surrounding CSF.[90]


Treatment

Medical Therapy

There is no consensus on the appropriate treatment for Erb's palsy since this will depend on the severity of the affection, age of the patient, and prognosis.[91] Treatment is often multidisciplinary and aimed to be as conservative as possible.[92]

  • Immobilization and splinting. It is commonly used during the first week from injury to avoid flexion contractures.[93]
  • Electrostimulation. Its use is still controversial.[94]
  • Hydrotherapy. It is a useful method of physical therapy, due to its anti-gravity properties, facilitates muscle relaxation, and range of motion; at the same time, it increases strength and muscle build-up due to water resistance.[95]
  • Physiotherapy: It can be done in combination with hydrotherapy or alone. Consist of passive and active range of motion, strengthening, and stretching exercises.[96]
  • Occupational therapy. It is usually required for adult patients with long-term damage to help them deal with daily-living activities (eating, tying shoes, playing, drawing).[97]

Surgery

Surgery is not the first-line treatment option for patients with Erb's palsy. Surgery is usually reserved for patients with no functional recovery from physical therapy and will depend on the time from damage, the cervical roots involved, and the patient’s age.[98]

In infants, surgical intervention is indicated if the motor function does not improve after 3 months of age.[99] After 20 to 24 months of denervation, exists a loss of neuro-muscular endplates, which makes the timing for surgery a crucial point.[100]

Surgical intervention includes nerve decompression, nerve repairs, and graft implantation, with great chances of success.[101]

One of the surgical procedures done for persistent cases is Hoffer-procedure, which has been shown to improve functional outcomes when operated before age 2.5 years.[102]

Secondary reconstruction procedures have been realized in patients as a last resource to gain partial functionality.[103] These include:

Primary Prevention

Effective measures for the primary prevention of Erb's palsy include prenatal screening to detect fetal, or maternal risk factors, and close management of mothers with diabetes and obesity.

Secondary Prevention

Effective measures for the secondary prevention of Erb's palsy include the application of shoulder dystocia maneuvers during labor (placement of mother in McRobert's position), and once detected a brachial plexus palsy, prompt medical or surgical management when necessary.

Tertiary Prevention

Effective measures for the primary prevention of Erb's palsy aims to improve functionality in patients with brachial paralysis through physiotherapy and occupational therapy.


References

  1. Dunn PM (1995). "Dr William Smellie (1697-1763), the master of British midwifery". Arch Dis Child Fetal Neonatal Ed. 72 (1): F77–8. doi:10.1136/fn.72.1.f77. PMC 2528415. PMID 7743291.
  2. Duchenne, Guillaume (1855). "De l'éléctrisation localisée et de son application à la pathologie et à la thérapeutique". France: Baillière.
  3. "Erb's palsy". Wikipedia. Retrieved 05/15/2020. Check date values in: |access-date= (help)
  4. Sarikcioglu L, Arican RY (2007). "Wilhelm Heinrich Erb (1840-1921) and his contributions to neuroscience". J Neurol Neurosurg Psychiatry. 78 (7): 732. doi:10.1136/jnnp.2007.115956. PMC 2117688. PMID 17575018.
  5. McGillicuddy JE (2011). "Neonatal brachial plexus palsy - historical perspective". J Pediatr Rehabil Med. 4 (2): 99–101. doi:10.3233/PRM-2011-0161. PMID 21955966.
  6. Narakas AO (1985). "The treatment of brachial plexus injuries". Int Orthop. 9 (1): 29–36. doi:10.1007/BF00267034. PMID 4018968.
  7. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
  8. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
  9. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
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==References== {{Reflist|2}}Template:Certain conditions originating in the perinatal period


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