Erb's Palsy/Brachial Plexus Injury

Abstract

The brachial plexus serves as the key conduit between the central nervous system and the extensive innervation of the upper extremity. One of the most common variants of injury to the brachial plexus results in the condition known as Erb's palsy, in which damage renders the arm disabled through a particular constellation of symptoms. The affected arm hangs down at one's side rotated inwardly with the elbow fully extended and forearm internally rotated.

With any peripheral neuropathy, an inā€depth knowledge of the anatomy aids in recognising the expected symptomatology. Several classification symptoms characterise the extent of damage after nerve injury, predict neuronal recovery and determine whether surgical repair is needed. In the past, amputation and simple neglect were standard treatments of care. Fortunately, outcomes have improved tremendously over the past few decades, and new procedures are emerging. Today, there are techniques that allow for significant return of function.

Key Concepts

  • Learn the anatomy of the brachial plexus.
  • Understand the result of injury to the upper trunk of the brachial plexus.
  • Erb's palsy from shoulder dystocia.
  • Basic classification and grading of nerve injuries.
  • Know which imaging is available to assess nerve injury.
  • Assessing nerve injury using electromyography (EMG) and nerve conduction studies (NCS).
  • Understand the basic surgical and nonsurgical management of brachial plexus injury.

Keywords: brachial plexus anatomy; Erb's palsy; brachial plexus injury; upper trunk injury; shoulder dystocia; electromyography (EMG); nerve conduction studies (NCS); compound muscle action potentials (CMAPs); sensory nerve action potentials (SNAPs)

Figure 1. Infant afflicted with Erb's palsy exhibiting the classic signs of ‘waiter's tip’. Matthew Skovgard.
Figure 2. The brachial plexus along with its branching nerves. Erb's point is where roots C5 and C6 converge to form the upper trunk (blue arrow). http://commons.wikimedia.org/wiki/File:Brachial_plexus_2.svg Creative Commons Attribution‐ShareAlike License.
Figure 3. Transection of spinal cord. Green arrow indicates sensory ganglion of peripheral nerve. Injury can be described around this point resulting in pre‐ or postganglionic injury. Red arrow indicates motor ganglion of peripheral nerve. Injury to motor components is always postganglionic in the setting of Erb's palsy because the ganglion is buried deep in the spinal cord. Image courtesy of and adapted from Ruth Lawson of Otago Polytechnic licensed under Creative Commons Attribution 3.0 Unported license.
Figure 4. (a) Primary and secondary mechanisms of nerve injury. (b) Factors that affect axonal regeneration after injury. Reproduced from Sulaiman et al. (2011) © Elsevier.
Figure 5. Algorithm illustrating approach to patients with acute nerve injuries. Reproduced from Sulaiman and Kline (2012) © Elsevier.
Figure 6. (a) The cylindrical structure indicated by the black arrow is a sciatic nerve with an intact nerve sheath. From outside of its sheath, the entire nerve appears to be normal and intact. (b) Using a scalpel to slice open the nerve sheath and expose the inner neuronal components of the sciatic nerve. (c) Exposure of the nerve shows considerable internal damage, haemorrhage and many ruptured individual nerve fascicles. Reproduced from Kim et al. (2014) © Elsevier.
close

References

Abzug JM and Kozin SH (2014) Evaluation and management of brachial plexus birth palsy. The Orthopedic Clinics of North America 45 (2): 225–232.

Belzberg A and Malessy MJ (2011) Early management of brachial plexus injuries. In: Winn HR (ed) Youmans Neurological Surgery, 6th edn, chap. 241. Philadelphia: Saunders.

Ducker TB (1980) Pathophysiology of peripheral nerve trauma. In: Omer GE and Spinner M (eds) Management of Peripheral Nerve Problems. Philadelphia: WB Saunders.

Ferrante MA (2004) Brachial plexopathies: classification, causes, and consequences. Muscle and Nerve 30: 547.

Ferrante MA and Wilbourn AJ (1995) The utility of various sensory nerve conduction responses in assessing brachial plexopathies. Muscle and Nerve 18: 879.

Gentili F , Hudson AR and Midha R (1996) Peripheral nerve injuries: types, causes, and grading. In: Wilkins RH and Rengachary SS (eds) Neurosurgery, pp 3105–3114. New York: McGraw‐Hill Company.

Highet J (1942) Effects of stretch on peripheral nerve. The British Journal of Surgery 30: 355–369.

Kim DH , Hudson AR and Kline DG (2014), External and internal neurolysis. In: Kim DH (ed) Atlas of Peripheral Nerve Surgery, 2nd edn chap. 21, pp 241–246. Philadelphia: Elsevier.

Kline DG and Hudson AR (1990) Acute injuries of peripheral nerves. In: Youmans J (ed) Neurological Surgery. Philadelphia: WB Saunders.

Kretschmer T and Birch R (2011) Management of acute peripheral nerve injuries. In: Winn HR (ed) Youmans Neurological Surgery, 6th edn, chap. 240. Philadelphia: Saunders.

Liu CT , Benda CE and Lewey FH (1948) Tensile strength of human nerves: experimental physiological and histological study. Archives of Neurology & Psychiatry 59: 322–336.

Lundborg G and Rydevik B (1973) Effects of stretching the tibial nerve of the rabbit. A preliminary study of the intraneural circulation and the barrier function of the perineurium. Journal of Bone and Joint Surgery (British) 55: 390–401.

Robinson L and Yuen EC (2011) Electrodiagnostic evaluation of peripheral nerves, electromyography and nerve conduction studies. In: Winn HR (ed) Youmans Neurological Surgery, 6th edn, chap. 232. Philadelphia: Saunders.

Schmitt C , Mehlman CT and Meiss AL (2008) Hyphenated history: Erb‐Duchenne brachial plexus palsy. The American Journal of Orthopedics (Belle Mead, NJ) 37 (7): 356–358.

Seddon HJ , Midha R and Kline DG (1998) Evaluation of the neuroma in continuity. In: Omer GE , Spinner M and Van Beek AL (eds) Management of Peripheral Nerve Problems, 2nd edn, pp 319–327. Philadelphia: WB Saunders.

Shin AY , Kircher MF , Spinner RJ and Bishop AT (2008) Treatment options for adult traumatic brachial plexus injuries. In: Slutsky DJ (ed) Upper Extremity Nerve Repair‐Tips and Techniques: A Master Skills Publication, pp 311–331. Rosemont: American Society for Surgery of the Hand.

Sulaiman OAR , Midha R and Gordon T (2011) Pathophysiology of surgical nerve disorders. In: Winn HR (ed) Youmans Neurological Surgery, 6th edn, chap. 230. Philadelphia: Saunders.

Sulaiman O and Kline D (2012) Outcomes of treatment for adult brachial plexus injuries. In: Chung K , Yang L and McGillicudy J (eds) Practical Management of Pediatric and Adult Brachial Plexus Palsies, chap. 24, pp 340–365. Churchill Livingston: Edinburgh.

Sunderland S (1978) Nerve and Nerve Injuries. Edinburgh: Livingstone.

Tharin BD , Kini JA , York GE and Ritter JL (2014) Brachial plexopathy: a review of traumatic and nontraumatic causes. AJR. American Journal of Roentgenology 202 (1): W67–W75.

Tiel RL , Happel LT Jr and Kline DG (1996) Nerve action potential recording method and equipment. Neurosurgery 39: 103–108.

Wilbourn AJ (2007) Plexopathies. Neurologic Clinics 25: 139.

Yang V and Fehlings MG (2011) Intraoperative monitoring of the spinal cord and nerve roots. In: Winn HR (ed) Youmans Neurological Surgery, 6th edn, chap. 269. Philadelphia: Saunders.

Further Reading

Ali ZS , Heuer GG , Faught RW , et al. (2015) Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. Journal of Neurosurgery 122 (1): 195–201.

Gherman R , et al. (2014) Neonatal Brachial Plexus Palsy was developed by the Task Force on Brachial Plexus Palsy. Obstertrics & Gynecology 123–4: 902–904.

Zafeiriou DI and Psychogiou K (2008) Obstetrical brachial plexus palsy. Pediatric Neurology 38 (4): 235–242.

Contact Editor close
Submit a note to the editor about this article by filling in the form below.

* Required Field

How to Cite close
Garces, Juanita, Mathkour, Mansour, Skovgard, Matthew, Kaufmann, Ascher, and Sulaiman, Olawale AR(Mar 2016) Erb's Palsy/Brachial Plexus Injury. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0025818]