Erb's palsy

How does this happen?

The C5 and C6 nerve roots leave the spinal cord in the neck and supply the muscles that lift the arm away from the body, turn it outward, and bend the elbow.

During birth, the head and shoulder can be pushed apart. That stretch falls hardest on the upper roots, which sit at the top of the bundle and take the most tension when the angle between neck and shoulder is widened. ²

The result is a specific posture, historically described as the waiter's tip position: the arm hangs at the side, rotated inward, the elbow straight, the forearm turned so the palm faces backward, and the wrist and fingers flexed but working.

The severity depends on the type of nerve injury, not on the label. A stretched nerve, called neurapraxia, recovers in weeks. A torn nerve that forms a neuroma recovers poorly. A root avulsion does not recover on its own. See the main brachial plexus page for the four injury types in detail. ¹

One complication to know about: if C7 is also involved, or if the injury extends, breathing can be affected because the nerve to the diaphragm arises nearby. A baby with an arm injury and any breathing difficulty needs urgent assessment.

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• shoulder dystocia managed correctly. The maneuvers used to free a stuck shoulder are forceful, and injury can occur despite correct technique. Guidance states this directly. ³
• Births with no shoulder dystocia recorded, and cesarean births, in which these injuries also occur. ³
• A large baby, where ultrasound weight estimates carry substantial error and cannot reliably predict who is at risk. ⁴
• Maternal diabetes, which changes how weight is distributed on the baby. ⁵
• breech birth or a very fast second stage. ⁶

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• A shoulder dystocia managed outside the recognized sequence, which begins with the McRoberts maneuver and suprapubic pressure. Fundal pressure is specifically discouraged. ³
• Excessive or wrongly directed traction on the head. ³
• Risk factors not considered, including when cesarean may be offered for suspected macrosomia. ⁴
• Gestational diabetes not screened for or not managed. ⁵
• The event not documented with the maneuvers used, in order, with times.
• The injury not recognized before discharge. ⁷
• Specialist referral delayed past the surgical window. ¹

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. These injuries occur after correctly managed births, and guidance says so plainly. ³

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• An arm lying limp at the side, turned inward, palm facing backward.
• Absent startle response on that side.
• A normal grip in the hand.
• Sometimes a broken clavicle on the same side.
• Any breathing difficulty needs urgent assessment.

The first week

• Continued lack of shoulder and elbow movement.
• A normal hand.
• Absent startle on one side.

Around 3 months

• Return of shoulder and elbow movement in babies recovering well.
• Persistent inability to bend the elbow against gravity, which is the key warning sign. ¹
• Early stiffness limiting outward rotation of the shoulder.

Around 6 months

• The checkpoint. No meaningful elbow bending against gravity by now means specialist surgical evaluation. ¹
• Tightness at the shoulder.
• Ignoring the affected arm and using only the other hand.

Around 12 months

• Weakness lifting the arm overhead.
• Difficulty turning the palm upward.
• A shorter arm on that side.
• Shoulder joint changes from long-standing muscle imbalance.

Toddler years

• Compensating by leaning or by using the mouth and the other hand.
• Difficulty with two-handed tasks.
• Limited overhead reach.

School age

• Functional limits in sport, dressing and self-care.
• Arm length difference.
• Shoulder surgery is sometimes considered in this period.

How is it diagnosed?

The diagnosis is clinical: a newborn whose shoulder and elbow do not work while the hand does.

Serial examination is the core of it. The same team assesses shoulder, elbow, wrist and hand separately, on a standardized scale, at intervals. What matters is the pattern of return over time, not any single visit. ¹

X-ray of the shoulder and collarbone to look for a clavicle fracture, and of the chest if breathing is a concern.

MRI of the brachial plexus where surgery is being considered, to look for root avulsion.

Look for Horner syndrome. A droopy eyelid and smaller pupil on the same side suggests lower root involvement and a more severe injury than pure Erb's palsy. If you notice this, mention it.

Any baby with this injury should be under the care of a specialist brachial plexus team. If nobody has raised referral by 3 months, ask for it. ¹

What is the treatment?

Daily range of motion from the start. Gentle movements taught by a therapist, done every day, to stop the shoulder and elbow from stiffening while the nerve recovers. This is the single most important thing a family does. ¹

Therapy. occupational therapy and physical therapy for range, for encouraging use of the arm, and later for function. Referral to early intervention gives access at no cost to families for a child under 3, and a diagnosed condition qualifies. ⁸

Nerve surgery where recovery stalls, generally between 3 and 9 months. Options are nerve grafting across a gap or nerve transfer, where a working nerve is rerouted to power an important muscle. Timing matters because muscle without a nerve signal eventually stops responding. ¹

Botulinum toxin in some children, to weaken a muscle that is overpowering its opposite while recovery happens.

Later surgery, including tendon transfers and bone procedures at the shoulder, to improve position and function in older children where the nerve result was incomplete.

What is the long-term outlook?

Erb's palsy has the best outlook of the brachial plexus injuries, because the upper roots are most often stretched rather than torn, and because a working hand means the most functionally important part of the arm is intact. ²

Most babies recover full or near-full function, and most of that happens in the first months. ¹

The best predictor is whether the elbow can bend against gravity by 3 to 6 months.

Where recovery is incomplete, the usual residual pattern is limited overhead reach, difficulty turning the palm upward, and a slightly shorter arm. Many children with residual weakness function very well.

What does daily life look like?

Daily stretches for months, which families consistently describe as the hardest habit to keep and the one that mattered most.

Small adaptations to dressing, car seats and carrying.

As the child grows, two-handed tasks are the practical challenge: bikes, jars, instruments, shoelaces. occupational therapy works on these directly.

Sport is usually possible. Ask the specialist what to avoid rather than assuming restriction.

What does care cost over a lifetime?

No agency publishes a lifetime cost for Erb's palsy, and this site does not invent one.

Cost is driven by therapy over months to years, by nerve surgery in a minority, and by later reconstructive surgery in some children. Where function largely recovers, long-term cost is low.

If a legal case is filed, the relevant figure is a life care plan written for your child rather than a population estimate.

What can you do this week?

1. Ask for the delivery note, including any shoulder dystocia note with maneuvers and times.
2. Get a therapy referral today and have the exercises demonstrated to you.
3. Ask whether the hand and the diaphragm are working.
4. Ask when specialist referral happens. If it has not been mentioned by 3 months, ask.
5. Ask whether the collarbone was X-rayed.
6. Film the arm weekly in the same position.
7. Request the complete records with the records request builder.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the specialist team

• Which nerve levels are affected, and what injury type do you suspect at each?
• What movements are you tracking, and what should I see by 3 and 6 months?
• At what point would you operate, and what would the operation be?
• Is there any sign of Horner syndrome?

For the therapist

• Show me the exercises and watch me do them.
• How often, and what does too much look like?
• How do we get my baby to use that arm?
• What position for sleeping and in the car seat?

You can also build a printable list with the question generator.