Case Study: Erb’s Palsy (Post-Traumatic Brachial Plexus Injury)

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Managed in Clinical Physiotherapy Setup | Continuing Sessions | 2010–2012

This was a case that came to me during 2010–2012 and left a lasting impression. A 10-year-old girl was brought in by her mother following a traumatic injury. She had been walking on the footpath when she was hit by a car, resulting in what was later diagnosed as Erb’s palsy—a type of upper brachial plexus injury.

Her mother shared that, after the accident, the child had lost the ability to bend or lift her right arm, and she could not move her shoulder, elbow, wrist, or fingers. The limb hung by her side with a characteristic "waiter’s tip" posture. It was understandably distressing for both the child and her family.

Presentation and Complaints:

• Complete weakness of the upper limb, especially shoulder abduction, elbow flexion, wrist, and finger movements

• No sensation loss, but the limb was flaccid and non-functional

• Difficulty in dressing, writing, and eating with the affected hand

• Psychological effects – the child seemed quiet, hesitant, and was avoiding using her hand altogether

Assessment (As Followed During 2010–2012):

• Observation showed shoulder subluxation and limp hanging of the limb

• Manual Muscle Testing (MMT): Grade 0–1 strength in deltoid, biceps, wrist extensors, and intrinsic hand muscles

• Passive range of motion (PROM) was maintained, but active ROM was absent

• No obvious joint contractures yet, but risk of stiffness was high

• Checked for compensatory movements and shoulder elevation during attempted use

• Pain was not a prominent issue, but emotional discomfort and reduced confidence were evident

Physiotherapy Management:

Although I don’t recall each session in detail, the treatment was a continuing rehabilitation plan, and we started seeing visible recovery with time. Based on her condition and our approach during that period, the following techniques and strategies were part of her therapy:

1. Positioning and Limb Protection:

  • Advised proper positioning of the arm to avoid joint stiffness and subluxation
  • Provided slings and soft supports to hold the shoulder in place when needed

2. Passive Mobilization and ROM Maintenance:

  • Gentle passive ROM exercises to the shoulder, elbow, wrist, and fingers
  • Aimed to prevent contractures and maintain joint health

3. Facilitation of Muscle Activation:

  • Tactile stimulation, brushing, tapping, and resistance in the flaccid muscles to encourage voluntary contraction
  • Weight-bearing activities on the upper limb (as tolerated) to promote joint stability and proprioception

4. Electrotherapy:

  • Although I don’t recall clearly, we commonly used Electrical Nerve Stimulation (ENS) during that time
  • We used low-frequency stimulation applied over the biceps, deltoid, wrist extensors, and hand muscles to stimulate activity and prevent disuse atrophy

5. Functional and Play-Based Therapy:

  • Integrated the child into playful activities and games involving reaching, holding, and pushing tasks
  • Focused on two-handed activities to encourage limb use during drawing, stacking, and ball games
  • Use of mirror therapy and visual feedback to promote awareness of the affected arm

6. Family Education and Home Program:

  • Educated the mother on the importance of daily home exercises
  • Demonstrated how to help the child with passive stretches and limb use during play
  • Advised on emotional encouragement, as the child’s mindset was key in recovery

Outcome:

Over time, we began to see visible signs of improvement:

• The child started to initiate shoulder and elbow movement

• Gradually, wrist and finger control improved, although fine motor control took longer

• Her confidence improved, and she began using the hand more during tasks

• The family was encouraged by the progress, and the mother remained fully involved in the rehab process

This case reminded me of how critical early intervention and continued encouragement are in pediatric neurological rehab. Even though full function may take time, the key is to keep the therapy meaningful, engaging, and consistent. Watching her regain her movements step-by-step was both inspiring and rewarding.


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