BrachialPlexusandErb’sPalsy

The brachial plexus is a network of nerves that exits the spinal cord between the vertebrae of the neck (C5 through T1) and travels through the shoulder to supply motor and sensory function to the entire upper limb. When those nerves are stretched, bruised, or torn during delivery, the resulting weakness can range from a transient palsy that resolves in weeks to a permanent paralysis that requires reconstructive surgery and a lifetime of therapy.

Injuries are classified by the location and severity of nerve damage. Neurapraxia is a mild stretch with the nerve sheath intact — most of these recover fully. Axonotmesis is a more severe stretch with axonal damage but preserved connective tissue — recovery is slow and partial. Neurotmesis is a complete rupture of the nerve. Avulsion — the most severe injury — occurs when the nerve root is pulled entirely off the spinal cord and cannot regenerate on its own.

Incidence data is reported by the American Academy of Orthopaedic Surgeons and the American College of Obstetricians and Gynecologists (ACOG), with outcome studies indexed on PubMed.

Most brachial plexus birth injuries follow a well-described sequence. After the head delivers, the anterior shoulder becomes impacted against the pubic bone — a shoulder dystocia. If the team recognizes the dystocia and moves immediately to the recognized algorithm — HELPERR (Help, Evaluate for episiotomy, Legs in McRoberts, Pressure suprapubically, Enter maneuvers, Remove posterior arm, Roll to hands and knees) — most dystocias resolve within 60 to 90 seconds without any significant injury.

The injuries happen when the algorithm is not followed. Specifically:

• Lateral head traction. Pulling the head laterally (away from the impacted shoulder) stretches the brachial plexus on that side. This is the single most common mechanism of preventable injury, and it is the one the standard of care most directly addresses.
• Fundal pressure. Pushing on the top of the uterus instead of the pubic bone can worsen the impaction and is explicitly contraindicated in shoulder dystocia management.
• Delay in reaching for posterior-arm delivery. If McRoberts and suprapubic pressure do not resolve the dystocia in the first minute, delivery of the posterior arm is the next step — and it is effective in the majority of cases. Delay in reaching this step means the baby is under compression longer.
• Failure to call for help. Shoulder dystocia is a team event. Anesthesia, additional nursing staff, neonatology, and a second obstetrician should be notified immediately. Teams that freeze or work alone do worse.

Moreover, some brachial plexus injuries are caused by the maternal forces of labor themselves — without any provider-applied traction. These are harder cases, and a qualified firm will retain a maternal-fetal medicine expert to review whether the mechanism of injury, the pattern of nerve damage, and the documented delivery support or undermine the malpractice theory.

Not every brachial plexus injury was foreseeable. Roughly half of shoulder dystocias occur in pregnancies with no identifiable risk factors. However, a meaningful fraction of the highest-risk pregnancies come with clear warning signs — and the standard of care requires the obstetric team to account for them:

• Maternal diabetes. Gestational or pre-existing diabetes causes disproportionate growth of the fetal shoulders and torso, sharply increasing dystocia risk. ACOG recommends offering elective cesarean delivery when estimated fetal weight exceeds 4,500 grams in a diabetic pregnancy.
• Fetal macrosomia. An estimated fetal weight above 4,500 grams in a non-diabetic pregnancy is a recognized risk factor. Discussion of mode of delivery should be documented.
• Prior shoulder dystocia. A history of shoulder dystocia in a previous delivery is one of the strongest predictors of recurrence. Repeat cesarean is often the safer course.
• Prolonged second stage. A second stage of labor that extends beyond three hours in a nulliparous patient or two hours in a multiparous patient is associated with increased dystocia risk.
• Operative vaginal delivery. Use of forceps or vacuum extraction roughly doubles the risk of shoulder dystocia when the delivery is not straightforward.

When several of these factors co-exist — for example, a diabetic mother with an estimated fetal weight above 4,500 grams and a prolonged second stage — a reasonable obstetrician will have documented the conversation about cesarean delivery well before the shoulder dystocia happens. The absence of that documentation is, itself, a piece of evidence.

The newborn with Erb's palsy shows a characteristic clinical picture. The affected arm hangs limp at the side in the classic “waiter's tip” posture — the shoulder rotated inward, the elbow extended, the forearm pronated, and the wrist and fingers flexed. The Moro reflex — the infant's startle response — is asymmetric, absent on the affected side. Passive range of motion is preserved, but active movement is weak or absent.

A complete evaluation at a specialty center typically includes serial neurological examinations by a pediatric neurologist or brachial plexus specialist, measurement of biceps return (the most-watched marker), imaging (MRI with myelography to assess for nerve-root avulsion), and nerve conduction studies at three to four weeks. The single most important prognostic marker is return of biceps function by three to six months. Infants who recover biceps strength by that window generally do well. Those who do not are candidates for nerve-reconstruction surgery — typically nerve grafting or nerve transfer — at a pediatric brachial plexus center.

A brachial plexus case in Florida typically requires two core expert reviews — obstetric for the delivery management, and pediatric neurology or pediatric orthopedic surgery for the extent and permanence of the injury. In more complex cases, a pediatric neurosurgeon or brachial plexus reconstructive surgeon may be added to address causation and damages.

Florida Statute § 766.102 requires a corroborating expert affidavit from a board-certified specialist in the same specialty as each defendant. That means the firm must have an obstetrician willing to opine, in writing and under oath, that the delivery team's management of the shoulder dystocia breached the standard of care and caused the injury — and a pediatric specialist willing to document the extent of the permanent impairment. This is a significant barrier, and cases without real expert support do not get filed.

The pre-suit investigation period is 90 days. The statute of limitations is tolled during that period. Once pre-suit closes without settlement, suit is filed and discovery begins.

Recoverable damages in a Florida brachial plexus case include:

• Past and future medical expenses. Pediatric therapy (often weekly for years), nerve-reconstruction surgery when indicated, secondary orthopedic procedures, adaptive equipment, and long-term rehabilitation costs projected over the child's life expectancy by a certified life-care planner.
• Lost earning capacity. Where a permanent arm impairment limits the child's realistic future career options, an economist calculates the difference between lifetime earnings with and without the injury.
• Pain and suffering. Non-economic damages for the child's own suffering, disfigurement, and loss of enjoyment of life. These damages are uncapped in Florida after North Broward Hospital District v. Kalitan, 219 So. 3d 49 (Fla. 2017).
• Loss of consortium. Available to parents whose relationship with the child is substantially impaired by the injury.

Severe cases — complete avulsion with permanent arm paralysis — produce life-care plans that project decades of therapy, multiple surgeries, and significant vocational limitation. These are serious cases, carefully defended, and no family should settle one without experienced trial counsel and a complete life-care plan in hand.

Parents often suspect something was wrong in the delivery room long before anyone tells them. If your child was born with a limp arm, required a brachial plexus consult, has been referred for nerve-reconstruction surgery, or is facing years of therapy, the next steps are the same:

1. Preserve the records. Request the complete labor-and-delivery record, the delivery note (which documents the maneuvers used), nursing notes, the fetal monitoring strip, and every pediatric neurology, orthopedic, and therapy consult.
2. Do not sign anything. Hospital risk managers sometimes reach out in the first weeks offering settlements or asking for recorded statements. Nothing good comes of signing before counsel has reviewed the file.
3. Document the course of care. Every therapy session, every milestone met or missed, every follow-up appointment — chronologically organized. This record is what the life-care planner will use later.
4. Contact a Florida birth-injury attorney. The evaluation is free. A qualified firm will order the records, retain a maternal-fetal medicine expert and a pediatric brachial plexus specialist to review the file, and tell you honestly whether the case is defensible under the standard of care.

Remember that the minor's extension to the 8th birthday is an outer limit, not a deadline to aim for. The strongest cases are the ones where the records are pulled early and reviewed before anything is lost.