Erb's palsy

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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 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.

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".[1]

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

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.[2][3]

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 compresion of the myelin sheet, with no structural damage to the axon.[4]
  2. Axonotmesis: Anatomic interruption of the myelin sheath and the axon of the nerve, but perneurium and epineurium remain intact.[5]
  3. Neurotmesis: Complete tear of the nerve, including the axon with his endoneurium, perineurium, and epineurium.[6]


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:[7]

  • Group I: Classic Erb's palsy (C5-C6 roots). Presents with abduction/external rotation of the arm and elbow flexion.[8]
  • Group II: Extended Erb's palsy (C5-C7 roots). Presents same as above plus drop wrist.[9]
  • Group III: Total palsy without Horner syndrome (C5-C8 roots). Presentation is a complete flaccid paralysis of the arm.[10]
  • Group IV: Total palsy with Horner syndrome (C5-T1). Presentation is a complete flaccid paralysis accompanied with ptosis, miosis, and anhidrosis.[11]


Pathophysiology

Erb's palsy is caused by damage to the upper brachial plexus, cervical roots C5-C6,[12] and in 50% of the cases, involving C7.[13][14] Although, damage can occur at any time, this usually happens during a delivery complicated by shoulder dystocia.[15] 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.[16] Another way of damage to upper brachial plexus can be made by excessive pressure on the baby's raised arm during a breech delivery. [17]

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.[18] Therefore, the patient is unnable to abduct or externally rotate the shoulder, as well as supinate the forearm because of weakness.[19]

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.

Differentiating Erb's palsy from other Diseases

Erb's palsy must be differentiated from:

  • Clavicular fracture.[20][21]
  • Osteomyelitis of the humerus or clavicle.[22]
  • Septic arthritis of the shoulder.[23][24][25]


Epidemiology and Demographics

The prevalence of Erb's palsy is approximately 90 to 206 per 100,000 in the United States,[26] while prevalence worlwide is approximately 50 to 500 per 100,000 live births.[27]

There is no racial predilection to Erb's palsy.

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

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

Patients of all age groups may develop [disease name].

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The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.

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[Disease name] commonly affects individuals younger than/older than [number of years] years of age.

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[Chronic disease name] is usually first diagnosed among [age group].

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[Acute disease name] commonly affects [age group].

[disease name].

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[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].

[Disease name] affects men and women equally.

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[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.

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

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[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Risk Factors

Common risk factors in the development of Erb's palsy include:

  • Maternal gestational diabetes
  • Maternal obesity
  • Shoulder dystocia
  • Macrosomia
  • Prolonged labor .Duration of second stage of labor(over 60 minutes) https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/
  • Breech presentation
  • Difficult extractions (need of forceps or other operative measures)
  • Shoulder dystocia in prior deliveries https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/

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.[28]

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.[29] Interestingly, a notable association was found between BPBP and fracture of the middle third of the clavicule.[30]

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

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According to the [guideline name], screening for [disease name] is not recommended.

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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].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

Although 75% of brachial plexus injuries resolve spontaneously and completely within the first month after birth, 25% result in permanent disability and impairment.[31]

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.[32]

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Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

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

  • Toronto test score
  • Active movement scale
  • Mallet scale
  • Toddler Arm Use Test https://www.physio-pedia.com/Erb%27s_Palsy


Diagnosis

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].

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The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

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The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

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There are no established criteria for the diagnosis of [disease name].

History and Symptoms

The majority of patients with [disease name] are asymptomatic.

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The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

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].

Biceps reflex absent, Moro reflex with hand movement but no shoulder abduction, palmar grasp present https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy

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.[33] https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy

waiter tip position Arm held limply adducted, internally rotated, and pronated with wrist flexed and fingers flexed (“waiter's tip” position)[34]

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Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

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The presence of [finding(s)] on physical examination is diagnostic of [disease name].

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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].

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Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

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[Test] is usually normal among patients with [disease name].

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Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].

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There are no diagnostic laboratory findings associated with [disease name].

Electrocardiogram

There are no ECG findings associated with [disease name].

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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].

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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].

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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].

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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].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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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].

  • X-rays of the chest - to rule out clavicular or humeral fracture
  • MRI of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
  • CT Scan of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots[8][9][10]
  • EMG/Nerve conduction studies- presence of fibrillation potentials indicate denervation
  • https://www.physio-pedia.com/Erb%27s_Palsy


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.[35]

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.[36]

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.[37]

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.[38]

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

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Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

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The majority of cases of [disease name] are self-limited and require only supportive care.

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[Disease name] is a medical emergency and requires prompt treatment.

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The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

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[Therapy] is recommended among all patients who develop [disease name].

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Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

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Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

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Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

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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.[39]

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.[40]

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.[41] https://www.sciencedirect.com/topics/medicine-and-dentistry/erbs-palsy

Primary Prevention

There are no established measures for the primary prevention of [disease name].

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There are no available vaccines against [disease name].

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Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

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[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.

https://www.roydswithyking.com/solicitors-for-life/medical-negligence-claims/birth-injury-claims/erbs-palsy-claims/erbs-palsy-info/causes-of-erbs-palsy/

References

  1. Dunn PM (1995). "Dr William Smellie (1697-1763), the master of British midwifery". Arch Dis Child Fetal Neonatal Ed. 72 (1): F77–8. doi:10.1136/fn.72.1.f77. PMC 2528415. PMID 7743291.
  2. Sarikcioglu L, Arican RY (2007). "Wilhelm Heinrich Erb (1840-1921) and his contributions to neuroscience". J Neurol Neurosurg Psychiatry. 78 (7): 732. doi:10.1136/jnnp.2007.115956. PMC 2117688. PMID 17575018.
  3. McGillicuddy JE (2011). "Neonatal brachial plexus palsy - historical perspective". J Pediatr Rehabil Med. 4 (2): 99–101. doi:10.3233/PRM-2011-0161. PMID 21955966.
  4. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
  5. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
  6. Menorca RM, Fussell TS, Elfar JC (2013). "Nerve physiology: mechanisms of injury and recovery". Hand Clin. 29 (3): 317–30. doi:10.1016/j.hcl.2013.04.002. PMC 4408553. PMID 23895713.
  7. Al-Qattan MM, El-Sayed AA, Al-Zahrani AY, Al-Mutairi SA, Al-Harbi MS, Al-Mutairi AM; et al. (2009). "Narakas classification of obstetric brachial plexus palsy revisited". J Hand Surg Eur Vol. 34 (6): 788–91. doi:10.1177/1753193409348185. PMID 19786407.
  8. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/B0-323-03386-5/X5001-2 Check |pmid= value (help).
  9. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/B0-323-03386-5/X5001-2 Check |pmid= value (help).
  10. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/B0-323-03386-5/X5001-2 Check |pmid= value (help).
  11. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/B0-323-03386-5/X5001-2 Check |pmid= value (help).
  12. Ivalde FC, Marazita-Valverde J, Bataglia D (2019). "Considerations For Surgical Planning Of Humeral Osteotomy In Brachial Plexus Birth Palsy Based On The Elbow Crease And Humeral Retroversion Measurement". J Ayub Med Coll Abbottabad. 28 (4): 479–480. PMID 31933294.
  13. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2009-0-55229-4 Check |pmid= value (help).
  14. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2010-0-68825-0 Check |pmid= value (help).
  15. "Erb's Palsy". Physiopedia. Retrieved 05/13/20. Check date values in: |access-date= (help)
  16. "Erb's Palsy". Physiopedia. Retrieved 05/13/20. Check date values in: |access-date= (help)
  17. "Erb's Palsy". Physiopedia. Retrieved 05/13/20. Check date values in: |access-date= (help)
  18. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2010-0-68825-0 Check |pmid= value (help).
  19. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2010-0-68825-0 Check |pmid= value (help).
  20. "Erb's Palsy". Physiopedia. Retrieved 05/13/2020. Check date values in: |access-date= (help)
  21. Peleg D, Hasnin J, Shalev E (1997). "Fractured clavicle and Erb's palsy unrelated to birth trauma". Am J Obstet Gynecol. 177 (5): 1038–40. doi:10.1016/s0002-9378(97)70010-3. PMID 9396889.
  22. "Erb's Palsy". Physiopedia. Retrieved 05/13/2020. Check date values in: |access-date= (help)
  23. "Erb's Palsy". Physiopedia. Retrieved 05/13/2020. Check date values in: |access-date= (help)
  24. Gabriel SR, Thometz JG, Jaradeh S (1996). "Septic arthritis associated with brachial plexus neuropathy. A case report". J Bone Joint Surg Am. 78 (1): 103–5. doi:10.2106/00004623-199601000-00014. PMID 8550666.
  25. Sharma RR, Sethu AU, Mahapatra AK, Pawar SJ, Nath A (2000). "Neonatal cervical osteomyelitis with paraspinal abscess and Erb's palsy. A case report and brief review of the literature". Pediatr Neurosurg. 32 (5): 230–3. doi:10.1159/000028943. PMID 10965268.
  26. "StatPearls". 2020. PMID 30020632.
  27. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2009-0-55229-4 Check |pmid= value (help).
  28. Ouzounian JG (2014). "Risk factors for neonatal brachial plexus palsy". Semin Perinatol. 38 (4): 219–21. doi:10.1053/j.semperi.2014.04.008. PMID 24863028.
  29. Gandhi RA, DeFrancesco CJ, Shah AS (2019). "The Association of Clavicle Fracture With Brachial Plexus Birth Palsy". J Hand Surg Am. 44 (6): 467–472. doi:10.1016/j.jhsa.2018.11.006. PMID 30685136.
  30. Asena M, Akelma H, Ziyadanoğulları MO (2020). "The relationship between the location of neonatal clavicular fractures and predisposing factors". J Neonatal Perinatal Med. doi:10.3233/NPM-190321. PMID 31985476.
  31. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2015-0-00649-9 Check |pmid= value (help).
  32. "StatPearls". 2020. PMID 30020632.
  33. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2009-0-60140-9 Check |pmid= value (help).
  34. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/C2009-0-55229-4 Check |pmid= value (help).
  35. "StatPearls". 2020. PMID 30020632.
  36. "StatPearls". 2020. PMID 30020632.
  37. "StatPearls". 2020. PMID 30020632.
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==References== {{Reflist|2}}Template:Certain conditions originating in the perinatal period


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