Erb’s Palsy vs Klumpke’s Palsy: Understanding Brachial Plexus Injuries

Understanding Erb’s Palsy vs. Klumpke’s Palsy: Key Differences in Birth Injuries

Birth injuries affecting the brachial plexus—the network of nerves controlling arm and hand function—represent some of the most serious complications that can occur during delivery. Two distinct conditions, Erb’s palsy and Klumpke’s palsy, both result from brachial plexus damage but affect different nerve locations with profoundly different consequences for the child’s development and function. Understanding the differences between these two conditions is essential for parents, healthcare professionals, and anyone navigating the medical and legal aspects of these injuries.

While both conditions fall under the umbrella of obstetric brachial plexopathy—occurring in 1 to 3 cases per 1,000 live births—their distinct characteristics mean different prognoses, treatment approaches, and long-term outcomes. Erb’s palsy, affecting the upper brachial plexus, is significantly more common, occurring in 0.9 to 2.6 per 1,000 live births, while Klumpke’s palsy, resulting from lower brachial plexus injury, accounts for a smaller percentage of cases.

The Brachial Plexus: Understanding the Anatomy

To understand the differences between Erb’s palsy and Klumpke’s palsy, it’s important to first understand the anatomy of the brachial plexus. This complex network of nerves originates from five nerve roots in the neck and upper back:

These five nerve roots combine to form three trunks: the upper trunk (C5-C6), middle trunk (C7), and lower trunk (C8-T1). These trunks then branch into the nerves that control shoulder, elbow, wrist, and hand movements. Any injury to these nerves during birth can result in varying degrees of paralysis and weakness depending on which specific nerves are affected.

Erb’s Palsy: Upper Brachial Plexus Injury

What Is Erb’s Palsy?

Erb’s palsy is a birth injury resulting from damage to the upper portion of the brachial plexus, specifically the C5 and C6 nerve roots—sometimes extending to C7. This condition accounts for approximately 85% of all brachial plexus birth injuries, making it by far the most common form of obstetric brachial plexopathy.

Causes of Erb’s Palsy

Erb’s palsy typically occurs when excessive lateral traction or stretching forces are applied to the baby’s head and neck during delivery. The most common delivery complications associated with Erb’s palsy include:

Several risk factors increase the likelihood of Erb’s palsy, including macrosomia (large birth weight relative to maternal pelvis size), maternal diabetes, maternal obesity, and breech presentation. However, Erb’s palsy can occur even in apparently low-risk deliveries when excessive force is applied during the birth process.

Symptoms and Clinical Presentation

Infants with Erb’s palsy typically present with a distinctive clinical appearance and set of symptoms:

The muscle groups primarily affected include the deltoid (shoulder), biceps (upper arm), and brachialis (deep arm muscle). Infants with Erb’s palsy typically show:

• Weakness or complete paralysis of shoulder abduction (lifting arm to the side)
• Inability to flex the elbow (bring hand toward face)
• Difficulty with external shoulder rotation (rotating arm outward)
• Diminished or absent reflexes in the affected arm (Moro reflex)
• Possible sensory loss in the outer shoulder and upper arm area
• Muscle atrophy (wasting) if nerve function doesn’t recover

Klumpke’s Palsy: Lower Brachial Plexus Injury

What Is Klumpke’s Palsy?

Klumpke’s palsy, also called Klumpke’s paralysis or Klumpke’s syndrome, results from injury to the lower brachial plexus, specifically the C8 and T1 nerve roots. In some cases, C7 involvement may also occur. This condition is significantly less common than Erb’s palsy, representing approximately 5-10% of brachial plexus birth injuries.

Causes of Klumpke’s Palsy

Klumpke’s palsy results from hyperabduction traction of the baby’s arm during delivery. The primary mechanism involves the arm being forcefully pulled or stretched above the head. Common scenarios include:

While Klumpke’s palsy can occasionally result from other forms of trauma or nerve injury in adulthood, in newborns it is almost exclusively a birth injury from improper delivery technique or failure to properly manage high-risk presentations.

Symptoms and Clinical Presentation

Infants with Klumpke’s palsy present with a distinctly different clinical picture than those with Erb’s palsy, primarily involving the hand and wrist:

The muscle groups primarily affected include the intrinsic hand muscles and flexor muscles of the forearm. Infants with Klumpke’s palsy typically show:

• Severe weakness or paralysis of finger flexion (inability to curl fingers)
• Weakness or paralysis of wrist flexion (difficulty bending wrist downward)
• Loss of fine motor control and grip strength
• Possible development of intrinsic minus hand deformity
• Sensory loss in the inner forearm and hand (C8-T1 dermatome distribution)
• Possible Horner’s syndrome if T1 nerve is severely damaged (drooping eyelid, constricted pupil)
• Muscle atrophy if nerve function doesn’t recover

Key Differences: Erb’s Palsy vs. Klumpke’s Palsy

Diagnosis and Medical Evaluation

Both Erb’s palsy and Klumpke’s palsy are typically diagnosed through clinical examination immediately after birth when parents or medical staff notice the characteristic postures and lack of movement in the affected arm. However, comprehensive diagnostic testing helps determine the severity of nerve injury and guide treatment decisions.

Clinical Examination

Physicians assess the infant’s ability to move the affected arm through a range of motion tests. Specific tests include:

Advanced Imaging and Testing

If nerve injury appears severe, additional testing may include:

• Ultrasound: Can visualize nerve roots and detect nerve root avulsion (complete separation from the spine)
• MRI Imaging: Provides detailed visualization of nerve damage and location of injury
• CT Scan: Can reveal bone injuries or fractures associated with the plexus injury
• Electromyography (EMG): Measures electrical activity in muscles to assess nerve function
• Nerve Conduction Studies: Tests how quickly electrical signals move through nerves

These advanced tests help physicians determine whether nerve damage is from stretching (neuropraxia, which typically recovers), from partial tearing (axonotmesis), or from complete nerve root avulsion (neurotmesis), which requires surgical intervention.

Treatment Approaches

Conservative Treatment

For both Erb’s palsy and Klumpke’s palsy, conservative treatment is the first line of intervention and is successful in the majority of cases when started early:

Critical Timing: Studies show that infants who begin physical therapy within the first four weeks of birth have the highest recovery rates. Treatment started within the first two weeks is associated with complete recovery in nearly 100% of cases when improvement is evident.

Surgical Treatment

If conservative treatment doesn’t produce improvement within three to six months, surgical intervention may be recommended. Surgical options include:

Surgical decisions typically depend on the extent of nerve damage (determined by advanced imaging and testing) and the child’s response to conservative treatment. Modern microsurgical techniques have significantly improved outcomes for children requiring surgical intervention.

Recovery and Long-Term Outcomes

Erb’s Palsy Prognosis

The prognosis for Erb’s palsy is generally quite favorable when treated appropriately:

• Complete Recovery Rate: 80-96% with proper early intervention
• First Year Recovery: 70-80% of infants achieve complete recovery within the first year of life
• Early Intervention Benefit: Nearly 100% recovery rate when treatment begins within the first four weeks and improvement is evident within the first two weeks
• Timeline: Most improvement occurs within the first 3-6 months, with continued gradual improvement through age 2-3 years

Even when complete recovery doesn’t occur, many children retain excellent function of the shoulder and elbow with targeted therapy and, if needed, surgical intervention. Long-term disabilities are relatively uncommon with appropriate treatment.

Klumpke’s Palsy Prognosis

Klumpke’s palsy generally has a favorable prognosis, particularly because many cases involve only neuropraxia (stretching without tearing):

• Recovery by 4 Months: 88% of infants recover by 4 months
• Recovery by 12 Months: 92% of infants recover by 12 months
• Mild Form Recovery: Most infants with neuropraxia (stretching injury) recover within 6 months
• Severe Form Outcome: Infants with nerve tearing (especially root avulsion away from the spine) may experience lifelong disabilities

The excellent recovery statistics for Klumpke’s palsy reflect the fact that lower brachial plexus injuries are often purely stretching injuries without nerve tearing. However, when root avulsion or severe nerve injury occurs, outcomes can be more complicated and may require surgical intervention.

Complications and Long-Term Effects

When nerve injuries are severe or recovery is incomplete, several long-term complications can develop:

Medical Negligence and Legal Considerations

While some cases of brachial plexus injury occur despite appropriate medical management, many cases result from medical errors or negligence during the delivery process. Understanding when these injuries might have been preventable is important for families considering legal action.

Common Causes of Negligent Injury

Brachial plexus injuries can result from:

• Failure to recognize risk factors (macrosomia, maternal diabetes, breech presentation)
• Improper management of shoulder dystocia using excessive lateral traction
• Inappropriate use of forceps or vacuum extraction with excessive force
• Failure to attempt alternative delivery techniques (Zavanelli maneuver, symphysiotomy)
• Unnecessary delay in recognizing and treating the condition
• Improper initial medical management or failure to refer for appropriate therapy

If your child has suffered an Erb’s palsy or Klumpke’s palsy injury during birth, consulting with both a medical expert and an experienced birth injury attorney is important to determine whether negligence played a role in the injury.

Conclusion

Erb’s palsy and Klumpke’s palsy are distinct brachial plexus birth injuries with different causes, locations of nerve damage, clinical presentations, and long-term outcomes. Erb’s palsy, affecting the upper brachial plexus and resulting in shoulder and elbow paralysis, is far more common but generally has an excellent prognosis with early treatment. Klumpke’s palsy, affecting the lower brachial plexus and resulting in hand and wrist paralysis, is less common but also typically has a favorable recovery rate when appropriate therapy is initiated promptly.

The critical factor in achieving the best outcomes for either condition is early recognition and aggressive conservative treatment, beginning within the first four weeks of life. For families facing the challenges of these injuries, understanding the differences between these conditions helps guide medical decisions and recovery planning. If your child’s injury resulted from medical negligence or improper delivery management, consulting with experienced legal professionals can help ensure your family receives appropriate compensation for ongoing care needs.

Get Help Today