Living with Erb's palsy or brachial plexus nerve injury

When someone mentions birth injury or birth trauma, we may immediately think about injuries to the baby’s head and brain, or physical and/or psychological injury to the mother. Whilst these types of injury are more commonly talked about in the NHS and in the media, a difficult birth can sometimes cause an entirely different form of injury to the baby - brachial plexus nerve damage - which leaves the baby with partial or complete paralysis to one arm. This serious condition is known as Erb’s palsy.

What is the brachial plexus?

The brachial plexus is a network of five nerves, including four of the lower cervical nerves (C5, C6, C7 and C8)  and the first thoracic nerve (T1), which run down the spinal cord and emerge from between the vertebrae in the neck, passing under the collarbone and forming the major nerves of the arm at armpit level. The brachial plexus nerves conduct signals from the spinal cord to the muscles and skin of the chest, shoulder, arm, and hand, giving movement and feeling to the arm.

What is Erb’s palsy?

Erb’s palsy is a condition in which the nerves which give movement or feeling to an arm are stretched, bruised or torn, causing weakness or paralysis in the arm. The severity and duration of the disability suffered by the injured baby can range from mild and short-term to lifelong and severe.

Are there different types of Erb’s palsy injuries?

Yes, but it is not always easy to categorise the injury into one or other of the types, which depend on the extent of the damage to the nerves. Identification of the type of injury can help with treatment decisions and make it easier to predict how the child will be affected by their injury in future.

The main types of Erb’s palsy injuries include:

• Neuropraxia​
  This type of nerve injury occurs when a nerve is stretched but isn’t torn. These injuries have a better prognosis (long-term outlook) than other types of Erb’s palsy injury and often resolve in a few months without treatment.
   
• Neuroma
  A neuroma is more serious stretching of the nerves which may partially improve with time but usually leaves scar tissue and some long-term damage.
   
• Rupture or tearing of the nerves
  These serious injuries need treatment with nerve grafting surgery.
   
• Avulsion
  ‘Avulsion’ refers to any injury where tissue that is attached to a bone is completely torn away from it. In Erb’s palsy injuries, an avulsion injury means that the nerve has been completely torn from the spinal cord. Surgery may be possible using healthy nerves from another part of the body but this is a very serious form of brachial plexus nerve injury. 

What causes Erb’s palsy?

Erb’s palsy is usually caused by excessive traction (pulling) on the baby’s head and shoulders during a vaginal delivery. The risk of Erb’s palsy increases where there is ‘cephalopelvic disproportion’ - which means that the baby’s head is disproportionately large for the size of the mother’s pelvis, either because the pelvis is small or unusually shaped, or the baby is big or is incorrectly positioned.

‘Shoulder dystocia’ can occur when the baby’s head descends into the birth canal but delivery is obstructed because one or both shoulders become wedged behind the mother’s pubic bone. As the baby’s head is pushed down the baby’s brachial plexus nerves are stretched. The baby appears stuck and requires very careful handling by the midwife or doctor to be delivered safely. Excessive pulling on the head during attempts to deliver the baby can cause damage to the brachial plexus nerves, resulting in Erb’s palsy.

Erb’s palsy can also be caused by pressure on the baby’s arms during a breech (feet first) delivery.

In childbirth, the risks of Erb’s palsy are also increased by:

• using extraction instruments during delivery (such as forceps);
• a lengthy second stage of labour;
• where the baby is large;
• maternal excessive weight gain.

What are the treatments for Erb’s palsy?

The milder form of Erb’s palsy may heal, in part or completely, by itself. For the best chance of recovery, it is essential that the injured baby undergoes tests as early as possible to find out which nerves have been damaged, so that any necessary treatment is started quickly. 

Treatment may involve:

• physiotherapy - to increase movement in the arms or shoulders and to improve grip strength in the hand;
• occupational therapy (OT) - to help the child manage daily activities, such as holding or picking things up;
• surgery, such as tendon/muscle release, or nerve grafting, which is needed in severe cases of Erb’s palsy to repair nerve damage and restore the ability to move the arm, shoulder or hand. The earlier the surgery takes place, the better the chances of success.

What are the effects of Erb’s palsy?

Each person’s experience of Erb’s palsy will be different, depending on which nerves are affected and the severity of the injury.  Long term effects can range from mild weakness or discomfort to total paralysis of the arm with permanent disability.

Effects of Erb’s palsy may include:

• total paralysis or weakness in one arm;
• numbness in one arm;
• the arm is held bent at the elbow and close to the body;
• the elbow is held straight and the hand is turned backwards – often called the ‘waiter’s tip’ position;
• reduced grip strength or a limp hand;
• drooping eyelid and small pupil of one eye on the affected side – Horner’s syndrome;
• head faces away from the affected arm and can’t face forwards for any length of time – known as torticollis;
• smaller sized and different shaped affected arm, from lack of muscle use;
• shorter affected arm from reduced bone growth (as a result of lack of muscle use);
• arthritis in later life from abnormal wear and tear on affected joints;
• circulation, muscular and nervous development may also be impaired.

Will Erb’s palsy affect my child’s ability to live and work independently? 

Restricted movement of the arm and shoulder, arm paralysis or weakness and reduced grip strength can make every aspect of life difficult at home, at school and at work, as well as affecting the ability to participate in some sports and leisure pursuits.

Every individual’s range of impairments will be unique, which is why we work closely with each client, their family and our experts to understand the ways in which their life is or will be affected or restricted by their disability before assessing the cost of alleviating their hardship and meeting their additional needs.

For example, our clients tell us that independence in routine tasks, like washing and brushing their hair, is one of the hardest things to achieve, owing to the difficulty with raising their injured arm above shoulder height. Cooking becomes more difficult and dangerous with a weakened or paralysed arm.

At school and later in home and work life, writing becomes a struggle where two strong, mobile arms and hands are needed to anchor a piece of paper with one hand and write with the other.  Some study and job options will be closed to those with impaired upper limb function or their career progression and earnings may be limited. Driving can also be difficult with a shortened or weakened injured arm. 

Children and young people may require support and counselling to help them cope emotionally with the psychological impact of managing and overcoming their disability in a competitive educational and workplace environment.

How does Boyes Turner help clients with Erb’s palsy or brachial plexus injury?

Boyes Turner’s birth trauma specialists have secured compensation settlements and awards for many clients with Erb’s palsy from mismanaged childbirth.

Our extensive experience of these claims, our understanding of the causes and lifelong effects of Erb’s palsy and the way this condition affects our clients’ lives, and our careful and thorough valuation of each client’s unique disability enables us to achieve the best settlements.

Where negligent birth injury has impaired our client’s ability to live their life to the full, we work to secure full compensation to alleviate financial hardship, provide necessary care, therapies, adapted accommodation and specialist equipment to restore our clients’ independence, financial security and quality of life.

If you or your child are suffering from birth-related disability and you would like to find out more about making a claim, contact us by email at cerebralpalsy@boyesturner.com.