Clavicle fracture in a newborn during childbirth

During childbirth, with a baby being born, various injuries occur, among which quite often there is a collarbone fracture. At the same time, the integrity of the clavicle can be compromised either completely or partially. Why is this happening?

Epidemiology

Clavicle fracture is one of the most common birth injuries of a newborn. [1] Statistics show that, on average, there are 11-12 cases of collarbone fracture in babies per 1,000 births. Clavicle fracture in a newborn was found in 1.65% of the total number of births. [2] Clavicle fractures complicated by 0.05% caesarean section. The main risk factor associated with a fracture of the clavicle during cesarean section was the birth weight of the baby. [3]

Causes of the collarbone fracture in a newborn

The shoulders of a baby in the womb are the widest part of the body, and it is on it that the main burden during childbirth lies. A collarbone fracture in a newborn occurs mainly when physical assistance is needed at the last stage of labor, aimed at pushing the fetus out of the mother's womb. To do this, use manipulations using forceps, vacuum, pulling on the handles, pressure on the bottom of the uterus in order to advance the child. The collarbone is vulnerable because represents a thin and fragile tubular bone. 

The causes leading to a collarbone fracture are most often:

• the fetus exceeds the size of the woman’s pelvic bone;
• transience of labor, in which the birth canal and pelvic bones are not ready for this;
• improper presentation of the fetus in the uterus, requiring the intervention of a doctor.

Risk factors

The risk factors for damage to the clavicle in newborns include the insufficient qualification of the obstetrician, as well as the fragility of the bones, the cause of which is a genetic disease. [4]

Pathogenesis

The pathogenesis of any fractures is associated with damage to the soft tissues adjacent to the bone, tendons, nerves, blood vessels. At the same time, the permeability of the capillary bed increases, edema develops at the site of injury, inflammation.

Symptoms of the collarbone fracture in a newborn

Most newborns with fractures in the early days of life lack symptoms and minimal physical data. [5] The first signs indicating a collarbone fracture in a newborn, an experienced neonatologist will determine immediately. The diagnosis is indicated by:

• hematoma;
• swelling;
• crying baby during swaddling;
• specific crunch when feeling the lesion;
• visually detectable bone deformity;
• limited hand movements.

Clavicle fracture with displacement in newborns

Due to the fact that the clavicle is surrounded by the periosteum - the connective tissue that protects the hollow bone from injury, fracture with displacement during childbirth is extremely rare. This is a more complex condition, sometimes requiring surgical treatment, when the bones are in different planes relative to each other.

In this case, the child exhibits increased excitability, is very sensitive to touch, there is a clear violation of the motor activity of the arm, the baby often refuses to breast, a pronounced hematoma and swelling appears. In these cases, in young children, healing and regeneration of bone tissue takes longer than usual and takes 1.5-2 months.

Complications and consequences

What is the danger of a collarbone fracture in a newborn? Consequences and complications are possible if the parents underestimate the situation and ignore the intervention of the doctor. In a fracture with displacement, the bone may not grow together correctly, which will cause problems in the future. A fracture in the medial third of the clavicle in a newborn can lead to the development of obstetric-shoulder paralysis with a frequency in the range from 4 to 13%. [6] The frequency of spontaneous recovery of paralysis of the brachial plexus of newborns is indicated as 75–95%, but it can vary depending on the degree of damage. [7] The risk of persistent neurological deficiency in brachial plexus paralysis associated with birth is lower than reported and the presence of a clavicle fracture may increase the likelihood of recovery. [8]

• How long does a newborn clavicle fracture heal?

Clavicle fracture is easily treatable. The bones in newborns are flexible, the bone tissue is soft. It takes a maximum of 3 weeks to fully heal. Healing features were first detected after 7 days (periosteal reaction), 11 days (callus), 20 days (connection) and 35 days (remodeling), respectively. Peak periods when each symptom was present: periosteal response 11-42 days, callus 12-61 days, connection 22-63 days and remodeling 49-59 days. [9]

Diagnostics of the collarbone fracture in a newborn

Most fractures of the clavicle of the newborn are diagnosed at discharge or at the first visit to a pediatric neonatalogue. In addition to examining a doctor who, based on the above criteria, palpation results, makes a preliminary diagnosis, to clarify, you will need instrumental diagnostics - an X-ray examination. [10]  Ultrasound should be the procedure of choice in the diagnosis of clavicle fracture. This is especially true in cases where impaired arm movement is the only clinical sign. [11]

Clinical suspicions of a collarbone fracture can be obtained from an anamnesis (dystocia of the shoulder) or clinical examination (sensation of spongy or crepitus on palpation). [12]

Blood tests, urine tests and others will help determine the general condition of the child.

Differential diagnosis

A collarbone fracture in a newborn is often difficult to diagnose, as it is often asymptomatic and can also be confused with other common diagnoses, such as brachial plexus paralysis, congenital pseudarthrosis and congenital muscular torticollis. Differential diagnosis is carried out between complete (with displacement, without it) and incomplete fractures (crack). Rarely, a child may have congenital collarbone pseudarthrosis, which is difficult to distinguish from a fracture. Pseudoarthrosis classically appears as a painless lump on the collarbone, without associated sensitivity or limitation of the mobility of the shoulder and arm. 

Treatment of the collarbone fracture in a newborn

First aid for a collarbone fracture in a newborn is to fix a hand bent at the elbow with which a broken clavicle is in contact. To do this, use a soft bandage that secures the limb to the body, an armpit is placed on the roller. [13]

It is important to monitor the condition of the skin of the hand: if you turn blue, consult a doctor, as this is a clear sign of a violation of the blood supply (the handle is tightly clamped). The child should not sleep on the side of the injury. Perhaps the use of painkillers ointments.

A breastfeeding mother needs to fill her diet with foods rich in vitamins, magnesium, calcium, phosphorus, silicon - minerals that help restore bone tissue. With severe bruising and edema, vitamin K can be prescribed intramuscularly (usually injected for 3 days).

After clavicle fusion, a rehabilitation period begins, including massage, magnetotherapy, electrophoresis, special exercises. [14]

Prevention

For the most part, the prognosis is favorable, only the rejection of hospitalization for a collarbone fracture in newborns with complex cases is fraught with violations of the musculoskeletal function of the joint, the development of infection.