What is the prognosis for a 6‑month‑old child with Erb’s (upper‑trunk) brachial plexus palsy who still cannot actively flex or extend the elbow?

Prognosis for Erb's Palsy Without Elbow Flexion/Extension at 6 Months

A 6-month-old child with Erb's palsy who cannot actively flex or extend the elbow has a poor prognosis for spontaneous recovery and requires immediate surgical intervention. 1

Critical Prognostic Indicator

The absence of active elbow flexion against gravity at 4-6 months is the single most important predictor of poor spontaneous recovery in birth brachial plexus injury. 1

• Children who lack active elbow flexion at 4 months have essentially no chance of complete spontaneous recovery and uniformly require surgical exploration and nerve reconstruction. 1
• In a prospective study, all infants without elbow flexion at 4 months (Group D) underwent surgical reconstruction, as spontaneous recovery did not occur. 1
• Conversely, infants who achieved elbow flexion by 2 months had 100% complete spontaneous recovery, and those achieving it by 3 months had satisfactory outcomes without secondary procedures. 1

Expected Functional Outcomes Without Surgery

Without surgical intervention at this stage, the prognosis is extremely poor:

• The child will likely develop a non-functional upper extremity with persistent weakness of shoulder abduction, elbow flexion, and forearm supination. 2, 3
• Secondary complications will develop, including muscle contractures of uninvolved muscle groups and glenohumeral joint subluxation or dislocation. 2
• Even if some shoulder function spontaneously returns, the hand will remain non-sensitive and non-functional without surgical intervention. 3

Surgical Intervention Urgency

Immediate surgical exploration and nerve reconstruction is indicated now, as the 6-month window represents the optimal timing for intervention. 1, 4

• Microsurgical nerve repair has demonstrated superior outcomes compared to conservative treatment in children who fail to recover elbow flexion by 4-6 months. 2
• Surgical options include nerve grafting for root avulsions or nerve fascicle transfers (ulnar and/or median nerve fascicles to musculocutaneous nerve branches). 4, 3
• Nerve fascicle transfers achieve functional elbow flexion in 87% of cases, with 77% obtaining full recovery against gravity. 4

Specific Functional Recovery Expectations After Surgery

If surgery is performed now:

• Elbow flexion recovery: 86-100% chance of achieving functional elbow flexion (ability to flex against gravity). 1, 4, 5
• Shoulder function: More variable, with 26-56% achieving stable shoulder with active external rotation, depending on extent of nerve involvement. 5
• Forearm supination: Less predictable, with only 21% achieving functional supination with single-fascicle transfers, though combined transfers improve this to 100%. 4
• Hand function: Requires additional focus during nerve reconstruction and typically takes longer to recover than proximal functions. 3

Critical Timing Considerations

Delaying surgery beyond 6-9 months significantly worsens outcomes, as the window for successful nerve regeneration narrows with time. 1, 4

• Younger patients at time of surgery achieve better supination recovery. 4
• The average delay between trauma and surgery in published series was 8 months, but earlier intervention (4-6 months) is now recommended based on prognostic indicators. 1, 5

Common Pitfall to Avoid

Do not adopt a "wait-and-see" approach beyond 6 months in a child without elbow flexion. The absence of this milestone by 4-6 months is definitive evidence that spontaneous recovery will not occur, and delaying surgery only compromises the final functional outcome. 1