What is the treatment for Erb's palsy?

Treatment of Erb's Palsy

Erb's palsy should be managed with early immobilization followed by passive range of motion exercises and active stretching, with surgical exploration of the brachial plexus reserved for infants showing no recovery by 3-5 months. 1

Initial Assessment and Diagnosis

• Erb's palsy presents as a flaccid arm hanging limply from the shoulder with wrist and finger flexion due to weakness of muscles innervated by cervical roots C5 and C6, creating the characteristic "waiter's tip" deformity 1, 2
• Rule out differential diagnoses including clavicular fracture, osteomyelitis, and septic arthritis before confirming Erb's palsy 1
• Risk factors include macrosomia and shoulder dystocia, though Erb's palsy can occur even following cesarean section 1

Conservative Management Approach

Early physiotherapy is the cornerstone of treatment and should begin immediately upon diagnosis:

• Start with early immobilization in the acute phase, followed promptly by passive range of motion exercises to prevent contractures 1, 3
• Passive stretching of tight scapulohumeral adductors and passive normal range of motion exercises to shoulder and elbow are essential 3
• Active range of motion exercises should be incorporated as the infant develops motor control 1
• Avoid airplane splints as they are probably harmful to the infant 3

Enhanced Physiotherapy Modalities

• Electrical stimulation (both galvanic and faradic current) may accelerate functional recovery compared to conventional physiotherapy alone 4
• Studies show significantly higher improvements in shoulder range of motion, elbow flexion, wrist extension, and arm circumference with electrical stimulation versus conventional approaches after 6 weeks of treatment 4
• Treatment frequency should be three times weekly for optimal results 4
• Functional electrical stimulation may be preferred for early resolution of function in Erb's paralysis 4

Complementary Approaches

• Ayurvedic treatments including medicated oil massage (Abhyanga) and processed rice paste application have shown benefit when combined with electrical stimulation 2
• Tactile stimulation and soft tissue manipulation techniques can be incorporated into the treatment regimen 4

Prognosis and Recovery Timeline

• The rate of complete recovery is 80% to 96%, especially if improvement begins in the first two weeks 1
• Most recovery occurs spontaneously with appropriate conservative management 1, 3
• Monitor closely for signs of improvement within the first 2 weeks, as this predicts excellent prognosis 1

Surgical Intervention Criteria

For infants with no recovery by 3-5 months, surgical exploration of the brachial plexus should be considered to improve outcomes 1

• Surgical options include nerve transfers, which can result in near-normal functional recovery when combined with multimodal management 5
• Triple nerve transfer techniques have been reported for optimal recovery of shoulder function in refractory cases 5
• Surgical timing is critical—waiting beyond 5 months without any improvement may compromise outcomes 1

Common Pitfalls to Avoid

• Do not use airplane splints, as they are likely harmful 3
• Failing to initiate passive range of motion exercises early can lead to permanent contractures and reduced functional outcomes 3
• Delaying surgical referral beyond 5 months in cases with no improvement reduces the potential for optimal recovery 1
• Even after muscle strength recovery, the "Erb engram" (abnormal movement pattern) may persist as a residual marker of the injury 3

Follow-Up Algorithm

• Assess for improvement at 2 weeks—early improvement predicts excellent prognosis 1
• Continue intensive physiotherapy with or without electrical stimulation for the first 3-5 months 1, 4
• If no recovery is evident by 3-5 months, refer immediately for surgical evaluation 1
• Long-term follow-up may be necessary to address residual functional limitations and abnormal movement patterns 3