Thanks to major medical discoveries, technological innovation and improved
doctor training, many serious and even devastating conditions are now much less
common than they were only a decade or so ago. For example, permanent damage
from strokes has been minimized; the birth and even conception of severely
defective fetuses have been prevented; and clogged coronary arteries are cleaned
up to reduce damage and deaths from heart attacks.
which is little known to the public and even many physicians, used to cause
temporary or even permanent disability among a significant number of newborns
around the world, including in Israel.
Erb’s syndrome – which can occur
as a result of brachial plexus injuries – fortunately is much less common than
it used to be. But the handful of affected newborns today must get the
rehabilitation they need to reduce their disabilities and even ensure normal
“Brachial” refers to the arm, while “plexus” (from the the
Latin for “braid”) is a branching network of nerves or blood vessels. The nerves
are typically peripheral ones outside the central nervous system. Erb’s (or Erb-
Duchenne) palsy is a paralysis of the arm caused by injury to the upper group of
the arm’s major nerves, specifically the severing of the upper-trunk C5 and C6
In 1861, Guillaume Benjamin Amand Duchenne gave a name to the
condition “obstetric palsy of the brachial plexus” after examining four babies
suffering from paralysis of identical muscles in the arm and
The syndrome was also named for Dr. Wilhelm Heinrich Erb, a
German neurologist who lived from 1840 to 1921 and used electricity to diagnose
and treat nervous disorders. He studied adult brachial plexus
Older children and adults can suffer from this condition as a
result of road accidents and other trauma to the head and shoulder, when the
nerves of the plexus are violently stretched.
Yet brachial plexus
injuries arise most commonly from shoulder dystocia during difficult birth.
Shoulder dystocia may occur when a baby’s head is delivered, but the shoulder
that is in the frontal position can’t pass through because the baby’s chin
presses against the walls of the perineum.
If a baby is stuck, obviously
it’s an obstetrical emergency, and in extremely rare cases, the infant can die
due to lack of oxygen because of pressure on the umbilical cord. If the baby
survives, there may be temporary paralysis that disappears on its own or with
physical and occupational therapy. But in a small minority of cases, physical
disability remains and even surgery is required.
An Israeli expert on
brachial plexus, Prof. Shlomo Weintroub is a pediatric orthopedist at the Dana
Hospital of Tel Aviv Sourasky Medical Center.
“The general public don’t
know about brachial plexus or Erb’s palsy at all,” he says. “It occurs [today]
much less frequently than before, and often if it’s a big baby, if the mother
suffers from regular or gestational diabetes or has a narrow pelvis and the
fetus can’t easily get out vaginally.”
“But better technology in delivery
rooms, more knowledge and awareness among midwives, obstetricians and ambulance
medics and other improvements have significantly reduced the number of cases we
see and the number of children with permanent damage.
This has created a
revolution in recent years, and there are only a few such children nationwide
Nevertheless, parents around the world whose children were
not saved from devastating injury pour out their hearts in blogs where they seek
advice and comfort.
ONE ISRAELI woman, A.D., writes that she has not one,
but two children with Erb’s palsy. “FR is not my first child with it. My oldest
son, now nine years old, was also born in a traumatic birth and his arm was
Only then, no one told me the truth about what happened at his
birth, and they still won’t. His folder in the hospital doesn’t even say
‘shoulder dystocia.’ “But on the second, while putting him down in his cot, I
saw his arm was limp. I freaked out thinking maybe I put him down too
She recalled that she rushed to the hospital nurses’ station,
but “they brushed it off, saying it was ‘probably from the birth, nothing to
worry about, definitely not my fault,’ and sent me to speak to the pediatrician
before we were discharged.
“He informed me that it was nerve damage from
being born, nothing major really, and that it would resolve within a few weeks.
And to go see a physical therapist. I really didn’t worry about it.”
her second birth, 18 months later, her son suffered from shoulder dystocia but
it resolved itself very quickly with no lasting damage.
“At that point, I
was told a C-section might be preferred but I thought – what’s the big deal?”
“Erb’s Palsy, I was told, is a condition that is temporary and
resolves itself. When my 3rd child was born and I told the hospital I was not
having the C-section, they were worried but she was born just fine. With the
knowledge I had at the time, I saw no reason to even worry about something
happening at birth, since all was fine, wasn’t it?”
She continued: “Along came FR three years ago. He was a really big baby. My doctor pulled him out, and it
was Erb’s palsy again. It was pretty traumatic; my son was totally white and
floppy when born... I asked the physiotherapist how long it would take until he
would be normal. I’ll never forget the sinking realization, as time went by,
that it was going to take forever – a lifetime affected by brachial plexus
injury, a child’s life forever changed because of the lack of information among
doctors and midwives out there.”
Another woman – a licensed physical
therapy assistant abroad – said she has trouble keeping a regular job because
she has to be available to take her daughter to her various treatments. “It
breaks my heart to see the crooked arm, with an abnormal size, that will never
Due to her injury, her daughter has no reflexes in her right
arm. “This means that as she was learning how to ride her bike, she once lost
control and fell flat on her face. Because she did not have a face-mask helmet,
she landed directly on her mouth. That was terrifying for her and for us, and we
quickly bought her a full-face helmet.”
After her first surgery, as
feeling started to return to her right hand, the girl began biting her right
index finger. “She was still too young to talk, but the doctor explained that it
would be the same feeling of your foot ‘falling asleep.’ We all know how painful
and annoying that is, but she didn’t know how to respond so she began biting
that finger. To the point that she had a chunk of flesh gone from it. I had to
start putting a tube sock over her right arm, then using masking tape to wrap it
on there so she couldn’t remove it and couldn’t keep biting her finger,” the
A woman from California described her 12-year-old
daughter who was born with the injury but is today an “accomplished intermediate
She was just chosen for the emerging athletes
program for swimming in the US Paralympics and will be training for 2020. She is
able to cope with her Erb’s palsy even though she is unable to do what most
human beings take for granted on a daily basis.”
Yet another woman
writing in the blog said that her second child had the disability for a week
after delivery, but “nothing was explained to me except that it ‘will get
better.’ By his two-week checkup it was. But I wasn’t informed and did no
research. Now my forth baby girl has it. It could have been prevented as all
warning signs were there; gestational diabetes, my major weight gain during
pregnancy and a history of large babies.
“Natalie’s arm woke up at three
months, but now at six months, her arm is still not 100 percent. She has
movement but not like a healthy baby. Now when I see a pregnant woman, I talk to
her and tell her my story and explain how it can be prevented.”
NOTED that midwives, obstetricians and MDA ambulance personnel are much better
trained and informed on prevention of brachial plexus injury
Cesarean sections – which in normal cases are not preferable to
vaginal births – are the delivery of choice if it seems likely that delivering
the baby will be difficult.
“And most babies that are born with it need
conservative treatment – physiotherapy and occupational therapy – rather than
surgery. With better physical exams and imaging, it’s much better for children
who do not recover on their own.”
A number of Israeli medical centers
have expert microsurgeons who work on peripheral nerves that were damaged during
birth, he continued. It used to be thought that severed or otherwise damaged
peripheral nerves cannot be repaired. But they can grow back and be fixed; the
central nervous system, however, still cannot be repaired.
“I don’t think
brachial plexus injuries can be completely eliminated. It will always be
sporadic, but with increased awareness during the last trimester of pregnancy
and the proper type of delivery, the cases will really be reduced,” said
Weintroub. “There are biotech companies working on techniques to encourage
peripheral nerves to grow, but if it works at all, this will take many years to
DR. SHIRLEY MEYER, a pediatric orthopedic surgeon by training
and a former director-general of Jerusalem’s Alyn Pediatric Rehabilitation
Center where she continues to practice medicine, says that it receives an
average of four new cases of brachial plexus injury children each year. This is
in addition to older youngsters who come from around the country to get
“The number of cesareans has shot up in the past decade.
It’s not good to do a cesarean as an elective procedure, but if a woman has
trouble delivering vaginally or if there are clear problems in her case, a
surgical delivery is preferable. Doctors and midwives are more liberal on this
than they used to be. Instead of using a forceps or vacuum delivery, they will
do a cesarean.”
Asked whether there are more cases at specific hospitals
– which would indicate a problem – Meyer said it is sporadic. When asked whether
there are more when babies are delivered in an ambulance or elsewhere when the
woman has not yet reached a hospital, she said no.
“When they don’t reach
the hospital in time, it usually is because it is sudden and the baby just slips
Alyn does not perform any surgery but sends young patients to
nearby Hadassah University Medical Centers or Shaare Zedek Medical Center to do
this. “If there is evidence of a tear in the nerves of the plexus, they can be
repaired by surgery around six weeks. Early surgery encourages regeneration,”
“When it’s an older child who suffers from residual injury at
the ages of three, four, five or six, we send them for surgery to transfer
muscles and even for cutting the bone and rotating the limb to its proper
But about half of these are left with some kind and degree of
DR. DANNY WEIGL, director of the orthopedics
rehabilitation clinic at the Schneider Children’s Medical Center in Petah Tikva,
trained in Miami and specializes in surgery for the
“Neurosurgery on the nerves never completely restores
functioning, so they need follow-up in orthopedics.
To improve the
results of physiotherapy, we often give Botox injections to reduce the tonus of
internal rotator muscles. This relaxes them for a few months, providing a window
of opportunity to repair some muscles. We do it with orthopedics and
physiotherapy, it really helps.
“Beyond the age of three or four years,
if the limb remains weak, we often add orthopedic surgery and transfer ligaments
His hospital currently has about 25 children under
treatment, with about five or six new cases a year.
“About 85 percent of
our children fully recover, higher than in Alyn because they may get the most
serious patients,” Weigl said.
He urges parents not to be afraid of
surgery as early as possible.
“When babies improve under physiotherapy,
some parents try to delay surgery, thinking that will make it all better. But
this often means the surgery will come too late, and without it, there will be
Another problem has nothing to do with medical treatments
but is social and educational. “These children often suffer from bullying and
ridicule from classmates, because they raise their arms awkwardly from the
shoulder and find it hard to play ball or put on their coats. They try to avoid
participating in gym classes. Healthy children should become used to being with
disabled children so they accept them,” he concluded.
Stay on top of the news - get the Jerusalem Post headlines direct to your inbox!