Erb's palsy: Difference between revisions

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{{CMG}}; {{AE}}[[Moises Romo|Moises Romo, 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]].      
==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="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".
*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 [[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="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>
*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 ==
Erb's palsy may be classified according to the severity of damage produced to the brachial plexus nerves as:


# '''Neurapraxia''': Mild, temporal disruption or compresion of the myelin sheet, 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>
*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>
# '''Axonotmesis''': Anatomic interruption of the myelin sheath and the axon of the nerve, but perneurium 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>


==Classification==


Erb's palsy, in turn, is also classified within the Narakas system, wich categorize Brachial Plexus Birth Palsy (BPBP) according to the roots envolved, 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>
*Erb's palsy may be classified according to the severity of damage produced to the brachial plexus nerves as:


* '''''Group I''':'' Classic Erb's palsy (C5-C6 roots). Presents with abduction/external rotation of the arm and elbow flexion.<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>
#'''[[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>
* '''''Group II''':'' Extended Erb's palsy (C5-C7 roots). Presents same as above plus drop wrist.<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>
#'''[[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>
* '''''Group III''':'' Total palsy without Horner syndrome (C5-C8 roots). Presentation is a complete flaccid paralysis of the arm.<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>
#'''[[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>
* '''''Group IV''':'' Total palsy with Horner syndrome (C5-T1). Presentation is a complete flaccid paralysis  accompanied with ptosis, miosis, and anhidrosis.<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>
 
*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>
**'''''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>


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==Pathophysiology==
==Pathophysiology==
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> Excesive upper traction to the baby's head when shoulder beign down produces stretching to the nerve fibers that can produce a simple temporal disruption or compresion, 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>


Superior trunk of the brachial plexus has motor and sensory fibers. Palsy of C5 and C6 roots affects movement of deltoid, biceps, brachialis, infraspinatus, supraspinatus, and serratus anterior muscles, as well as sensation of the skin of the shoulder and anterolateral forearm.<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> Therefore, the patient is unnable to abduct or externally rotate the shoulder, as well as supinate the forearm because of 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>
*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 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>
 
<br />
==Causes==
==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.
 
*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 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==
==Differentiating Erb's palsy from other Diseases==
Erb's palsy must be differentiated from:
Erb's palsy must be differentiated from:


* 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 a positive "piano key sign".
*[[Klumpke paralysis|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>
* 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" />
*[[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 [[White blood cell count|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>


<br />
<br />
==Epidemiology and Demographics==
==Epidemiology and Demographics==


* 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 worlwide 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>
*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>  
*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>
* Permanent impairment occurs in 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>
*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>
* In 2007, a study made by Weizsaeker et al found that african descendence 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>
*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 />


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


1. Mothers risks:


*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]]


[Chronic disease name] is usually first diaThe incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
2. Fetal risks:


OR
*[[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>


3. Labor risks:


[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.
*[[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>


The majority of [disease name] cases are reported in [geographical region].
*[[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>


OR
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>


[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].
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>
==Risk Factors==
Common risk factors in the development of Erb's palsy include:


* Maternal gestational diabetes
<br />
*Maternal obesity
==Screening==
* Shoulder dystocia
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:
* 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="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>
*[[Pelvis|Pelvic]] measurements. Will inform us if the maternal [[pelvis]] is narrow and its form (gynaecoid, anthropoid, platypelloid, android), which could complicate the delivery.


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="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> Interestingly, a notable association was found between BPBP and fracture of the middle third of the clavicule.<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>
*Serum glucose measurements. Will inform us of maternal [[diabetes]], which is directly associated with macrosomic children.
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].


OR
*[[Prenatal]] [[ultrasound]]. Will inform us of the [[fetal]] presentation and the approximate fetal weight.


According to the [guideline name], screening for [disease name] is not recommended.
Once the child is delivered, several findings that can make us suspect an Erb's palsy:


OR
*Negative ipsilateral [[Moro reflex]], and positive palmar [[grasp reflex]].
*[[Muscle]] tone and [[movement scale]].


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.<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>
 
Erb's palsy generally has a favorable prognosis and can be completely resolved in the first year of life if recovery begins with four weeks. However, if the muscle remains dennervated then without reinnervation, the injury becomes irreversible at 18 to 24 months. These time-sensitive, irreversible changes are the scientific basis for early management recommendations.<ref name="pmid3002063263">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
 
OR
 
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].


OR
[[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>


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
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>   


* Toronto test score
Common long term complications of Erb's palsy include:
* Active movement scale
* Mallet scale


* Toddler Arm Use Test    <nowiki>https://www.physio-pedia.com/Erb%27s_Palsy</nowiki>
*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 />


<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===
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===


OR
*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 reflex|Moro reflexes]] are absent with [[hand]] movement and palmar grasp present (differentiating factor from [[Klumpke paralysis|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>
*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>
*[[Ultrasound]] is many times the initial study when there is a suspected [[Glenohumeral joint|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 diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 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===
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
===CT scan===


The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
*[[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>
*CT [[myelography]] used to be the gold standard for evaluation of [[Nerve root|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>


OR
===MRI===


There are no established criteria for the diagnosis of [disease name].
*[[MRI]] can detect the same findings as [[CT scans]], with greater sensitivity for soft tissues.
=== History and Symptoms ===
*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 root|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>
The majority of patients with [disease name] are asymptomatic.


OR
<br />


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].
==Treatment==
=== Physical Examination ===
===Medical Therapy===
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].
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>
 
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>
 
The patient is unable to abduct or externally rotate the shoulder. The patient  of the supinator muscle. Sensory involvement is usually confined along the deltoid muscle and 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>               <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
 
waiter tip position Arm held limply adducted, internally rotated, and pronated with wrist flexed and fingers flexed (“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>
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
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].
=== X-ray ===
There are no x-ray findings associated with [disease name].
 
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 ===
There are no CT scan findings associated with [disease name].
 
OR
 
[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 ===
There are no MRI findings associated with [disease name].
 
OR
 
[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].
*Immobilization and [[Splint (medicine)|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>
=== Other Imaging Findings ===
*[[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>
There are no other imaging findings associated with [disease name].
*[[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>
*[[Physical therapy|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>


OR
===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>


[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].
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>
=== Other Diagnostic Studies ===
There are no other diagnostic studies associated with [disease name].


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>


[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].
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:


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].
*[[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>


* X-rays of the chest - to rule out clavicular or humeral fracture
*[[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>
*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>


* MRI of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
===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.


* CT Scan of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
===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]].
* EMG/Nerve conduction studies- presence of fibrillation potentials indicate denervation
* <nowiki>https://www.physio-pedia.com/Erb%27s_Palsy</nowiki>


<br />
<br />
==Treatment==
=== Medical Therapy ===
1-Hydrotherapy: It is a form of physical therapy used because of the anti-gravity environment. It minimizes the stress on the musculoskeletal frame, allowing the neonate to move with less pain and at the same time strengthening muscles and reducing spasms. Paralyzed muscles relax in the opposite position of the waiter's tip posture by abduction at the shoulder, external rotation of the arm, and supination of the forearm. In addition, hydrotherapy helps encourage normal movements in the affected arm.<ref name="pmid3002063253">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
2-Physiotherapy: Physiotherapy is either done alone or in combination with hydrotherapy. Response to the therapy varies from patient to patient with some healing earlier than others. Physical therapy can be required for severe cases to accompany surgery or in case of mild condition to work them through strengthening the area and healing on their own. Various forms of physical therapy exercises may include gentle stretching exercises, sensory stimulation, range of motion exercises and strength exercises.<ref name="pmid3002063243">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
3-Occupational therapy: Occupational therapy is usually required after the surgery or for those who sustained long-term damage to help them deal with everyday activities such as eating, tying shoes, playing, drawing, and more.<ref name="pmid3002063233">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
4-Surgery: Surgical intervention is the last resort and usually put on hold unless there is no functional recovery by physical therapy. Surgical intervention includes nerve graft and nerve decompression. Nere graft has the best chances of success.<ref name="pmid3002063223">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30020632 | doi= | pmc= | url= }}</ref>
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
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].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
=== 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="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>
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="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>
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.<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> <nowiki>https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy</nowiki>
=== Primary Prevention ===
There are no established measures for the primary prevention of [disease name].
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 ===
There are no established measures for the secondary prevention of [disease name].
OR
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
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>
==References==
==References==
{{reflist|2}}==References== <nowiki>{{Reflist|2}}</nowiki>{{Certain conditions originating in the perinatal period}}
{{reflist|2}}==References== <nowiki>{{Reflist|2}}</nowiki>{{Certain conditions originating in the perinatal period}}

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

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:


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 the delivery.
  • Serum glucose measurements. Will inform us of maternal diabetes, which is directly associated with macrosomic children.

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 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

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  2. Duchenne, Guillaume (1855). "De l'éléctrisation localisée et de son application à la pathologie et à la thérapeutique". France: Baillière.
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==References== {{Reflist|2}}Template:Certain conditions originating in the perinatal period


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