Purpose and Goal: CNEP # 2030

  • Understand the effects of birth trauma in the neonate.
  • Learn about the effects of clavicular fracture in the neonate.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for successful completion:

  • Successfully complete the post-test
  • Complete the evaluation form

Date

  • December 2015 – December 2017

Learning Objectives

  • Describe the risk factors for birth trauma in the neonate.
  • Describe the signs of clavicular fracture in the neonate.
  • Identify 2 approaches for the treatment of clavicular fractures.

Introduction

  • Injury during birth is an adverse effect
  • It should be suspected following difficult delivery
  • Birth injuries increase morbidity and mortality
  • Clavicular fractures occur in up to 4% of deliveries

Risk Factors for Injury

  • Birth trauma is any injury sustained during birth
  • Some birth trauma is avoidable
  • Some birth trauma is not avoidable
    • Injuries occur despite skilled providers
    • Injury typically occurs from manipulation
    • Manipulation occurs due to difficult delivery
  • Risk factors for injury may be related to:
    • The fetus
    • The mother
    • The type of delivery
  • Fetal risk factors
    • Macrosomia
    • Shoulder dystocia
    • Post-term gestation
    • Perinatal depression
    • Abnormal presentation
    • Prolonged second stage
  • Maternal risk factors
    • Obesity
    • Diabetes
    • Small stature
    • Large weight gain
    • Pelvic abnormalities
  • Delivery risk factors
    • Instrumented delivery
    • Operative vaginal delivery

Fractures of the Clavicles

  • Clavicular fractures:
    • Are the most common fracture in neonates
    • Are the second most common birth injury
      • Soft tissue injuries are most common
    • Are highly associated with shoulder dystocia
  • The clavicle is easily fractured because:
    • It is located anteriorly
    • It is located subcutaneously
    • It is frequently exposed to pressure
  • The middle third of the clavicle:
    • Is known as the midshaft
    • Is not protected by muscle
    • Is thin and easily fractured
  • Fractures should be suspected:
    • With all shoulder dystocia
    • With any decreased arm movement
  • Many infants are asymptomatic
    • Diagnosis may be delayed
    • Diagnosis may be missed
  • Fractures are often picked up at follow up
    • Callous formation occurs by 1 month
    • Callous formation is readily palpated
  • The type of fracture determines signs/symptoms
  • Signs of clavicular fracture include:
    • Crepitation or swelling
    • Decreased arm movement
    • Bruising over affected shoulder
  • Clavicular fracture is confirmed with x-ray
  • Fractures may also be confirmed with ultrasound

Types of Clavicular Fractures

  • The diagnosis of clavicular fractures
    • Depends on the type of fracture
    • Depends on the timing of presentation
  • Clavicular fractures may be:
    • Displaced fractures
      • Also known as complete
    • Nondisplaced fractures
  • Displaced fractures are more likely to:
    • Be identified in the post delivery period
    • Be accompanied by physical findings
      • Edema
      • Crepitus
      • Decreased movement
      • Asymmetrical bone contour
      • Crying with passive movement
  • Nondisplaced fractures are more likely to:
    • Be present without signs or symptoms
    • Be identified days or weeks after delivery
      • Up to 40% are not identified at birth
    • Be accompanied by callous formation
      • Callous may be visible
      • Callous may be palpable
  • Diagnosis of type of fracture is made by x-ray
    • Differentiates type of fracture
    • Differentiates fracture from shoulder dislocation
    • Differentiates fracture from brachial plexus injury
      • Up to 9% of affected infants have both

Treatment of Clavicular Fractures

  • Most fractures do not require treatment
  • They can be treated conservatively
    • With observation
  • Most fractures heal spontaneously
    • With no long-term sequelae
  • The affected extremity may be immobilized
    • Generally for 7 – 10 days
    • By pinning the affected sleeve
      • To prevent movement
      • Affected elbow should be flexed
      • Affected arm should be abducted
  • Immobilization decreases painful movement
    • Tylenol can be considered if pain persists
  • Most fractures have an excellent prognosis
  • Co-morbidities determine outcome
    • Associated brachial plexus injuries
    • Associated phrenic-nerve palsy

Summary

  • Traumatic birth injuries may be seen in neonates
  • Clavicular fractures the second most common injury
    • Most fractures do not require treatment
  • Most fractures heal without long-term problems
  • The early recognition of fractures is important
    • To decrease parental fear and anxiety
    • To alleviate pain associated with movement

References

  1. Parker, L. A. 2005. Part 1: Early Recognition and Treatment of Birth Trauma: Injuries to the Head and Face. Advances in Neonatal Care, 5 (6), p. 288-297.
  2. Parker, L.A. 2006. Part 2: Birth Trauma: Injuries to the Intraabdominal Organs, Peripheral Nerves, and Skeletal System. Advances in Neonatal Care, 6 (1), p. 7-14.
  3. McKee-Garrett, T.M. 2015. Neonatal Birth Injuries. Up-To-Date.
  4. Mavrogenis, A.F., Mitsiokapa, E.A., Kanellopoulos, A.D., Ruggieri, P. and Papagelopoulos, P.J. 2011. Birth Fracture of the Clavicle. Advances in Neonatal Care, 11 (5), p. 328-331.

Evaluation

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