Clavicle fracture in a newborn: causes and treatment

A clavicle fracture in a newborn is one of the most common injuries occurring during difficult vaginal births, especially when the shoulders are obstructed. In most cases, the injury is localized in the middle third of the bone and proceeds favorably, healing quickly and not requiring surgical treatment. The key task for the physician and family is to recognize the condition, rule out concomitant brachial plexus injury, and provide gentle care until recovery. [1]

Typical manifestations include localized swelling, pain with arm movement, crepitus, asymmetry of the Moro reflex, and so-called pseudoparalysis of the arm, when the child moves the limb less due to pain. Clinical examination is usually sufficient for diagnosis. When in doubt, imaging is used, with ultrasound increasingly becoming the preferred method in neonatal children as an accurate and safe method. [2]

Most clavicle fractures in newborns heal without sequelae within a few weeks. For comfort, gentle immobilization with simple clothing, correct positioning, and gentle care are used. Tight fixation and complex dressings are usually unnecessary. [3]

It is important to be aware of the possibility of concomitant brachial plexus injury, which occurs primarily with shoulder dystocia. Therefore, with any shoulder girdle injury during childbirth, it is necessary to check active joint movement and muscle tone of both upper limbs. If neurological deficit is suspected, the child requires in-depth examination and observation. [4]

Table 1. Quick Facts

Paragraph	Briefly
What is this	Traumatic fracture of the clavicle during childbirth
How does it manifest itself?	Pain when moving the arm, asymmetry of the Moro reflex, local swelling
How to confirm	Medical examination, ultrasound if necessary
How to treat	Gentle immobilization with clothing, gentle care, pain control
Forecast	Favorable, fusion within a few weeks

Source: Review guidelines and clinical articles on birth injuries.[5]

Epidemiology and risk factors

The reported prevalence of clavicle fractures in neonates varies across centers, ranging from approximately 0.2% to 4.4% of all births. The incidence is influenced by the method of delivery, fetal weight, and obstetric factors, particularly shoulder dystocia. These differences are due to differences in diagnostic criteria and population characteristics. [6]

Important risk factors include high birth weight, shoulder dystocia, instrumental delivery, and certain characteristics of the pregnancy and birth process. Some studies point to the contribution of maternal age and paragravidity. These variables help identify the study group but do not reliably predict injury in a specific child. [7]

Shoulder dystocia, as an obstetric emergency, carries a risk of soft tissue and bone injury, as well as transient brachial plexus injury. Therefore, preventive and therapeutic algorithms for shoulder dystocia indirectly impact the risk of clavicle fracture in newborns. [8]

Prevalence in individual institutions often reflects the pattern of pregnancies observed and obstetric tactics. This emphasizes the importance of standardizing techniques for difficult shoulder removal and training teams in safe maneuvers. [9]

Table 2. Factors associated with clavicle fracture at birth

Group of factors	Examples
Fruit	Above average body weight, large fetus
Obstetrics	Shoulder dystocia, instrumental delivery
Maternal	Senior reproductive age according to individual data
Institutional	Features of tactics and skills of the brigade

Sources: Reviews of birth injuries and risk factor studies.[10]

Pathogenesis and mechanism of damage

The fracture occurs due to excessive extension-torsion forces on the clavicle as the shoulder girdle passes through the birth canal. In shoulder dystocia, compression and traction may exceed the elastic limits of the bone, leading to a fracture, most often in the middle third. This mechanical event often protects the brachial plexus from more severe injury. [11]

The neonatal clavicle has a cartilaginous structure with a relatively thin cortical plate and high remodeling capacity. Therefore, even with fragment displacement, a massive bone callus forms and the anatomy is quickly restored without intervention. This biological reserve explains the favorable outcome in the vast majority of cases. [12]

Combined brachial plexus injury often reflects the degree of difficulty at birth rather than the fracture itself. However, it is the identification of neurological signs that determines the need for more careful monitoring and management. [13]

Table 3. Mechanisms and consequences

Mechanism	Possible outcome
Compression and traction of the shoulder girdle	Fracture of the middle third of the clavicle
The protective role of fracture	Reducing the load on nerve structures
High bone remodeling capacity	Rapid healing of large calluses
Combined injury	Transient brachial plexus lesion

Sources: obstetric manuals on shoulder dystocia and review articles on clavicle fractures.[14]

Clinical picture

Classic signs include localized swelling and tenderness over the clavicle, crepitus on gentle palpation, limited spontaneous arm movement on the affected side, and an asymmetric Moro reflex. The child may hold the arm close to the body, which is sometimes mistakenly interpreted as a neurological deficit. A proper assessment is based on comparison with the other arm and analysis of active hand and finger movements. [15]

The general condition is generally unaffected. Body temperature is normal, and the skin is unremarkable. Severe pain in newborns is rare and is easily managed with gentle care and, if necessary, simple analgesics in age-appropriate doses as prescribed by a physician. [16]

Signs of brachial plexus damage should be specifically sought: decreased tone and weakness in the shoulder and elbow joints with intact hand movements, and asymmetric grasp reflexes. The presence of neurological symptoms requires dynamic observation and, if deficits persist, consultation with a specialist. [17]

Table 4. Clinical clues for the initial examination

Sign	What suggests a fracture?
Asymmetry of the Moro reflex	Less pronounced on the damaged side
Hand position	Pressed to the body, less active movements due to pain
Palpation	Pain and crepitus above the collarbone
Leather	Often unchanged, sometimes slight swelling
Neurological status	Check the brachial plexus and grasp reflex

Source: clinical observations and neonatological reviews. [18]

Diagnostics

In most newborns, the diagnosis is made clinically. Imaging is necessary in cases of atypical findings, the absence of obvious palpable symptoms, or to clarify the location of the injury. Given the absence of ionizing radiation and its high accuracy, high-resolution ultrasound is increasingly the method of choice in neonatology. It allows visualization of the fracture line and developing bone callus without exposing the child to radiation. [19]

Radiography remains an available method of confirmation, but in the neonatal period it is advisable to reserve it for situations where ultrasound is unavailable or yields conflicting results. Routine imaging is not necessary for typical clinical presentations. [20]

If multiple injuries or atypical fractures are present in the first weeks of life, the need for a more extensive examination is decided on an individual basis. Assessment for other injuries is conducted based on clinical indications, taking into account the timing and mechanism of delivery. [21]

Table 5. Selection of diagnostic confirmation method

Situation	Preferred method	Comment
A typical clinic	Clinical diagnosis without imaging	Observation and care
An unclear picture, controversial signs	Ultrasound examination	High precision, no radiation exposure
Lack of access to ultrasound	X-ray	Perform when clinically necessary

Sources: systematic review and clinical guidelines. [22]

Differential diagnosis

A clavicle fracture should be differentiated from birth trauma to the brachial plexus without a fracture, from a fracture of the proximal humerus, and from rare conditions such as congenital pseudoarthrosis of the clavicle and metabolic bone diseases. The diagnosis is based on examination data, pain distribution, and imaging results, if necessary. [23]

Brachial plexus lesions present with more pronounced motor impairments in the shoulder and elbow joints while maintaining hand motion, whereas isolated clavicle fractures are more often associated with pain. This distinction helps formulate a monitoring and rehabilitation plan. [24]

Table 6. How to distinguish the main conditions

State	Pain on palpation of the clavicle	Moro	Hand movements	Visualization
Clavicle fracture	Eat	Asymmetrical	Saved	The fracture line is visible
Brachial plexus lesion	No local pain	Asymmetrical	Weakness may occur	Bone norm
Fracture of the proximal humerus	The pain is deeper in the shoulder area	Asymmetrical	May suffer from pain	Fracture line in another area

Sources: reviews of birth injuries. [25]

Treatment

In the vast majority of cases, a conservative approach is sufficient. This includes restricting the movement of the affected arm through clothing and positioning, gently lifting the baby, latching the baby to the breast in gentle positions, and pain control as prescribed by the doctor. Special tight bandages and complex orthoses are generally not necessary in neonatology. [26]

A practical technique widely used in clinical observations is to fasten the long sleeve of clothing on the injured side to the front of the undershirt, so that the elbow remains bent and the arm does not make excessive movements. This method of immobilization is well tolerated by the child and provides sufficient rest for healing. [27]

Pain control is achieved through a combination of gentle handling and, if necessary, simple analgesics in age-appropriate dosages as recommended by a physician. Additional interventions are usually not required. It is important for parents to understand the safety of the developing callus and the expected recovery time. [28]

Table 7. Conservative tactics

Component	What to do
Immobilization	Use clothing and sleeve support to limit movement
Laying down and carrying	Support the torso, avoid traction on the forearm and hand
Feeding	Choose comfortable positions that relieve tension from the injured side
Pain control	According to indications, prescribe an analgesic in an age-appropriate dose.
Family education	Explain the timing and nature of recovery

Sources: clinical descriptions and practical guidelines. [29]

Home care and observation

Typically, pain subsides by the end of the first week, and after two weeks, a painless bone callus is palpable. Full functional recovery takes several weeks, after which there are no further limitations. A follow-up examination by a pediatrician is necessary to assess progress and rule out neurological complications. [30]

Parents are advised to dress their child carefully, avoid lifting the child under the arms, and avoid sudden shoulder abduction on the injured side. During bathing and care, use gentle techniques, temporarily shifting the load to the healthy side. These measures are temporary. [31]

Table 8. Home plan for the first weeks

Week	Goals and benchmarks
First	Gentle regimen, sleeve fixation, pain control, family education
Second	Reduced pain, callus formation, expanded care
Next	Return to normal care, follow-up assessment with a pediatrician

Source: Clinical guidelines for families. [32]

Complications and prognosis

The prognosis is favorable. Fusion occurs rapidly, and bone remodeling is effective at this age. A noticeable callus may persist for some time, but it gradually smooths out and does not affect function. Chronic sequelae are rare. [33]

The main clinically significant risk is concomitant brachial plexus damage. In most children, neurological symptoms regress, but if they persist, observation and, if necessary, consultation with a pediatric neurologist and rehabilitation specialist are required. [34]

Table 9. When to refer to a specialist

Reason for routing	Who to refer to
Persistence of neurological symptoms	Pediatric neurologist, rehabilitation specialist
Atypical clinical presentation or repeated injuries	Pediatric orthopedist, neonatologist
Suspected other injuries	According to the profile of the identified pathology

Source: Obstetric and pediatric guidelines. [35]

Prevention at the delivery room level and training of teams

Standardized shoulder dystocia management, including consistent use of safe maneuvers, minimizing excessive traction, and teamwork, helps reduce the risk of injury. Training obstetric teams and practicing algorithms on simulators reduce the likelihood of injury in newborns. While it is impossible to completely prevent dystocia, the quality of management significantly influences the outcome. [36]

Following the birth of a child with a shoulder girdle injury, it is important to immediately conduct a targeted examination for bone and nerve damage, document findings, and organize follow-up. This ensures timely identification of associated problems and proper communication with the family. [37]

Table 10. Preventive Emphasis for Obstetric Teams

Stage	Priority
Recognizing dystocia	Quickly call for help and follow the algorithm
Maneuvers	Consistency and gentle technique without excessive traction
Post-natal examination	Evaluation of bone integrity and limb function
Communication	Explaining the nature of the injury and the monitoring plan to the family

Sources: Shoulder Dystocia Practice Sheets. [38]

Frequently asked questions

Is this dangerous for the baby?
Generally, no. A clavicle fracture in a newborn heals quickly and without consequences, provided gentle care and monitoring of possible neurological symptoms. [39]

Do all children need x-rays?
No. If the clinical picture is typical, an examination is sufficient. If in doubt, an ultrasound scan is preferable. [40]

How long will the child's movement be limited?
Discomfort typically subsides significantly by the end of the first week, and full recovery takes several weeks. [41]

Can I bathe and lay my baby on his stomach?
Yes, but be careful. During the first few days, use gentle techniques, gradually returning to normal care as the pain subsides. [42]

When should you see a doctor outside of a scheduled visit?
If pain increases, swelling is severe, skin color changes, hand and finger movement is reduced, arm weakness is present, or the condition worsens overall. [43]