Erb’s Palsy or Waiter’s Tip Hand In The Neonates

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Erb's palsy
Image Source: KINESIOLOGY & SPORT REVIEW

Two cases of neonates with Erb’s palsy, reflecting light upon the recovery times of the injury.

Erb’s palsy or the waiter’s tip hand is the result of injury to nerve roots, C5 and C6, at the point where C5 and C6 unite to form the upper trunk of the brachial plexus.  However, around 50% of the patients may also have C7 affected. Usually, the affected babies immediately diagnosed due to the arms hanging limply from the shoulder with internal rotation of the forearm plus wrist and finger flexion.

Approximately, two-thirds of the cases are in babies with shoulder dystocia during labour. However, other contributing factors include a very rapid or a prolonged second stage of labour, multiparous women, and obstetrical manoeuvres (controversial).

Case 1: Erb’s Palsy with complete, spontaneous, and rapid recovery

A baby boy was born to a 29-year-old woman via assisted vaginal delivery with artificial rupture of membranes. The fluid was meconium stained. The obstetricians used low-forceps, however, the delivery as difficult due to shoulder dystocia. The baby weighed 4398 g.  Baby’s APGAR scores were 4 and 8 at 1 min and 5 min, respectively. Right after birth, the obstetricians could immediately observe the right Erb’s palsy with no deltoid and weak bicep function.

By the age of 5 weeks, the baby had shown significant improvement. He regained spontaneous deltoid contraction (90° of abduction). Additionally, his biceps were able to flex his arm against gravity. Wrist and finger extensors were both normal.

At the 3-month follow-up, the baby showed complete recovery.

Case 2: Waiter’s Tip hand with slow recovery

A nulliparous woman gave birth to a baby weighing 4200 g. Due to decreased foetal tone, the doctors had to induced labour. They used low vacuum suction for assisting the vaginal delivery. The obstetrician also had to apply suprapubic pressure, McRoberts manoeuvre, and a ‘corkscrew’ manoeuvre due to moderate shoulder dystocia. At 1 and 5 minutes, the APGAR scores were 9 and 9. Immediately after birth, the doctors could notice severe right Erb’s palsy with little wrist extension and no bicep or deltoid function.

 By the age of 6 weeks, the baby had not regained bicep or deltoid function; however, the brachioradialis and triceps were normal. Moro reflex demonstrated supraspinatus contraction only, with a few degrees of abduction.

There were hopes of improvement, however, a plastic surgery assessment was scheduled in case if there would be no improvement by the age of 5 months.

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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