What is Erb’s palsy?
Erb’s palsy is weakness or paralysis of the arm caused by an injury to the upper nerves of the brachial plexus, specifically the fifth and sixth cervical nerves (C5–C6), most often when a baby’s neck is stretched away from the shoulder during a difficult delivery. It is the most common form of brachial plexus birth injury. The classic result is an arm held straight and turned inward against the body (the “waiter’s tip” posture) because the muscles of the shoulder and upper arm have lost their nerve supply.
The condition is also called Duchenne-Erb palsy, after the two physicians who described it. The encouraging news, covered in depth on our recovery page, is that a large share of babies regain full or near-full function, many within the first months of life. The harder news is that a minority do not, and for them early, expert treatment is what preserves the arm.
The nerves involved: C5–C6
The brachial plexus is a bundle of nerves running from the spinal cord in the neck, across the top of the chest, and into the arm; it powers every movement and sensation from shoulder to fingertip. Erb’s palsy involves the upper roots of that bundle, C5 and C6 (sometimes C7). These roots control the deltoid and biceps and the muscles that lift the arm out to the side and rotate it outward. When they are stretched or torn, the shoulder cannot abduct and the elbow cannot flex; hence the inward-rotated, straight-arm posture. Grip is usually spared, because the hand is powered by the lower roots (C8–T1), the roots involved in Klumpke’s palsy.
What causes Erb’s palsy
Erb’s palsy is a traction injury: the angle between the baby’s head and shoulder is widened forcefully, stretching the upper brachial plexus. The recognized contributors are:
- Shoulder dystocia: the shoulder lodges behind the pubic bone and lateral traction on the head stretches the nerves. This is the dominant mechanism; see how shoulder dystocia should be managed.
- Macrosomia: a large baby, often associated with maternal gestational diabetes.
- Instrument-assisted delivery: forceps or vacuum extraction.
- Breech delivery and other malpositions requiring manipulation.
- Prolonged second stage of labor.
A minority of cases arise from in-utero forces or maternal anatomy and can occur without excessive traction, a fact that also shapes the legal analysis below.
Signs and symptoms
- Arm held limp and straight, rotated inward (the “waiter’s tip” position)
- No movement at the shoulder or elbow on the affected side
- Preserved grip and finger movement (in classic upper-root injury)
- Absent Moro (startle) reflex on the affected side
- Sometimes an accompanying clavicle fracture
Severity: the Narakas classification
Clinicians grade obstetric brachial plexus injury on the Narakas scale, which predicts recovery and guides the timing of surgery. It matters legally too, because it frames how severe and how permanent an injury is.
| Narakas group | Nerves involved | Typical features | General prognosis |
|---|---|---|---|
| I | C5–C6 | Classic Erb’s palsy; shoulder and biceps affected, hand spared | Most favorable; high rate of spontaneous recovery |
| II | C5–C7 | Erb’s plus wrist-extension weakness | Good, but recovery slower and less complete |
| III | C5–T1 | Complete arm palsy (global) | Guarded; many need surgery |
| IV | C5–T1 with Horner’s syndrome | Complete palsy plus a droopy eyelid/small pupil, signaling root avulsion | Poorest; surgery usually required |
Treatment and recovery
Care begins conservatively and escalates only if recovery stalls. The foundation is physical and occupational therapy to keep the joints supple while the nerve heals, covered fully on our treatment and exercises page. When there is little or no recovery by around three to six months, evaluation for nerve reconstruction (nerve graft or nerve transfer) is considered, generally best done before the child is a year old. Whether a given child will recover, and what factors predict it, is the subject of our dedicated will my child recover page.
Was your baby’s Erb’s palsy the result of how a shoulder dystocia was handled? The delivery records hold the answer — and reviewing them with our attorneys costs nothing.
Was it preventable?
Not every case of Erb’s palsy is malpractice. Some injuries occur despite a properly managed delivery, and a subset arise from forces that no clinician controls. But Erb’s palsy is also the classic injury of a mishandled shoulder dystocia: excessive lateral traction on the head when recognized maneuvers (McRoberts positioning, suprapubic pressure, and the rest of the HELPERR sequence) were called for instead. The standard of care asks whether the risk factors were recognized, whether the dystocia was managed with technique rather than force, and whether the resulting injury was documented and referred promptly. When excessive traction is what caused the nerve to tear, the injury was likely preventable.
Legal options for families
An Erb’s palsy claim asks whether the delivery fell below the standard of care and whether that failure caused the nerve injury. Because the classic cause (excessive traction during shoulder dystocia) is well described in the medical literature, these cases turn on the delivery records, the documented maneuvers, and expert review of how force was applied. Compensation can cover therapy, reconstructive surgery, adaptive needs, and lost future earning capacity; published Erb’s palsy settlements illustrate the range, though every case is different and prior results never guarantee an outcome. Each state sets its own filing deadline; see our statute of limitations guide.
Where your case is handled depends on where the birth occurred: Banville Law attorneys are licensed in New York and Washington, D.C.; The Weitz Firm attorneys are licensed in Pennsylvania and New Jersey; elsewhere, the alliance connects families with its vetted network of local birth injury attorneys.
Frequently asked questions
Is Erb’s palsy permanent?
Often it is not. A large proportion of babies with C5–C6 (Narakas I) injuries recover full or near-full function, many within the first months. More severe injuries (global palsy or those with Horner’s syndrome) are more likely to leave lasting weakness and may need surgery. Our recovery page covers the statistics.
What is the difference between Erb’s palsy and a brachial plexus injury?
Erb’s palsy is a specific type of brachial plexus injury: the one involving the upper roots (C5–C6). The brachial plexus is the whole nerve bundle; injuries to its lower roots cause Klumpke’s palsy, and injury to all roots causes global palsy.
Does an Erb’s palsy always mean the doctor did something wrong?
No. Some cases occur despite careful delivery or from forces outside the clinician’s control. But because the classic cause is excessive traction during shoulder dystocia, these injuries deserve a records review to determine how the delivery was managed.
When should surgery be considered?
When there is little or no recovery of biceps function by roughly three to six months, an evaluation for nerve graft or nerve transfer is typically considered, ideally before the first birthday.
Sources
- American Academy of Orthopaedic Surgeons (AAOS). Brachial Plexus Birth Palsy (Erb’s Palsy).
- Narakas AO. Obstetrical brachial plexus injuries. In: The Paralysed Hand. Churchill Livingstone.
- National Institute of Neurological Disorders and Stroke (NINDS). Brachial Plexus Injuries Information.
- American College of Obstetricians and Gynecologists (ACOG). Neonatal Brachial Plexus Palsy (Task Force report).
- Chauhan SP, et al. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Seminars in Perinatology.
This page is for general education and is not medical advice. Medical facts above are drawn from the cited primary sources; legal statements reflect the reviewing attorneys’ professional experience. Always consult your child’s physician about medical concerns.