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222: ERB PALSY

Eric Shamus, PhD, DPT, PT, CSCS; Mae L. Yahara, MS, PT, ATC

CONDITION/DISORDER SYNONYMS

  • Erb–Duchenne palsy

  • Erb paralysis

  • Brachial plexus injury

ICD-9-CM CODES

  • 767.6 Injury to brachial plexus due to birth trauma

  • 953.4 Injury to brachial plexus

ICD-10-CM CODES

  • G54.0 Brachial plexus disorders

  • P14.0 Erb paralysis due to birth injury

  • S14.3XXA Injury of brachial plexus, initial encounter

PREFERRED PRACTICE PATTERNS

  • 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1

  • 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2,3

FIGURE 222-1

Schematic of the brachial plexus showing the branches, cords, divisions, trunks, and roots. (From Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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FIGURE 222-2

Axillary block. The axillary, musculocutaneous, and medial brachial cutaneous nerves are usually spared with an axillary approach. (From Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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PATIENT PRESENTATION

Patient is a 3-month-old infant. His mother reports a difficult birth. Review of the medical record reveals shoulder dystocia and forceps delivery. The mother is concerned about the right arm. Child exhibits poor tone in the right shoulder and upper arm, forearm extended and in pronation. No movement of the right arm on Moro reflex. No flexion of the arm with painful stimulus.

KEY FEATURES

Description

  • Paralysis of the arm

  • Weakness in the arm

  • Diminished reflexes C5–C6 vertebrae

  • Arm hangs by side, internally rotated

  • Motor or sensory changes in the nerve distribution due to pressure from

    • Compression

    • Stretch

Essentials of Diagnosis

  • Electromyography

  • Pain

  • Numbness

  • Sensory changes in multiple peripheral nerves of the upper extremity from C5 and C6 nerve roots

  • Hand clumsiness, weakness

  • Seddon classification

    • Neuropraxia (Class 1), First degree

    • Axonotmesis (Class 2), Second degree

    • Neurotmesis (Class 3)

      • Third degree, nerve fiber interruption

      • Fourth degree, epineurium intact

      • Fifth degree, complete transection of the nerve

General Considerations

  • Involved nerves: Suprascapular nerve, musculocutaneous nerve, axillary nerve

  • Must differentiate from more proximal and distal nerve compression, thoracic outlet syndrome (TOS), ulnar tunnel, cervical radiculopathy

  • Lower motor-neuron syndrome

  • Nerve compression syndrome in the upper extremity

  • Wallerian degeneration occurs below the site of injury

Demographics

  • Traction injury

  • Falls on outstretched arm (affects any age)

  • Infants: From birth trauma, head traction

CLINICAL FINDINGS

SIGNS AND SYMPTOMS

  • Acute or chronic paresthesia

  • Sensory ...

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