The Association of Clavicle Fracture With Brachial Plexus Birth Palsy

Neonatal upper limb fractures - a narrative overview of the literature

The aim of this paper is to review the topic of neonatal fractures of the upper limb, describing the different types of fractures focusing on the etiology, epidemiology, risk factors, clinical approach, diagnosis, treatment and prognosis of these injuries. We included all types of research studies, both experimental and observational, published in English, French, Portuguese and Spanish. The information was obtained using the keywords neonatal upper limb fracture, clavicle fracture or humerus fracture from the following resources: MEDLINE database, Embase® database and LILACS database. Other resources such as hand searches of the references of retrieved literature and authoritative texts, personal and hospital libraries searching for texts on upper limb neonatal fractures, discussions with experts in the field of upper limb neonatal fractures and personal experience, were also considered for the completion of the article.Neonatal fractures of the upper limb are consensually considered to have a good prognosis and no long-term sequelae. Conservative treatment is the option in the vast majority of the fractures and is associated with excellent results, with good healing, full range of motion, adequate remodeling without obvious deformity, neurologic impairment or functional implications.

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening

AIMS

The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP.

METHODS

EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher.

RESULTS

Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy.

CONCLUSIONS

Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

Incidence changes in risk factors associated with the decreasing number of birth-related clavicle fractures in Finland: A nationwide retrospective birth cohort from 2004 to 2017

BACKGROUND

A clavicle fracture is one of the most common birth injuries. The objective of this study was to examine whether the decreased incidence of birth-related clavicle fractures in Finland is because of temporal changes in their predisposing factors.

METHODS

For this nationwide population-based study, we used the Finnish Medical Birth Register and the Care Register for Health Care databases. The study population included all singleton, live-born newborn born spontaneously or by vacuum-assisted delivery, in cephalic presentation ≥37⁺⁰ weeks of gestation. The incidences of clavicle fractures, pregnancy characteristics, and risk assessments for fracture were calculated and compared between two time periods: 2004-2010 and 2011-2017.

RESULTS

A total of 629 457 newborn were born vaginally between 2004 and 2017. The clavicle fracture incidence decreased from 17.6/1000 to 6.2/1000 live births. Shoulder dystocia, diabetes, and birthweight ≥4000 g were the strongest predisposing factors. The incidence of birthweight ≥4000 g decreased, meanwhile type 1 diabetes and shoulder dystocia remained stable and gestational diabetes, type 2 diabetes, and maternal obesity increased in the later study period. The incidence of clavicle fractures without known predisposing factors declined. Simultaneously, the cesarean birth rate remained stable (13.2%-13.1%), although the rate of vacuum-assisted deliveries increased (8.5%-9.5%).

DISCUSSION

The incidence of clavicle fractures decreased, even though the incidence of most risk factors remained stable or increased, and the cesarean birth rate remained stable. This decline may be related to the reduction of fracture incidence among deliveries without known risk factors, and the decrease in birthweight ≥4000 g.

Newborn Clavicle Fractures: Does Clavicle Fracture Morphology Affect Brachial Plexus Injury?

BACKGROUND

Newborn clavicle fractures and brachial plexus injuries (BPIs) are rare but serious perinatal complications.

METHODS

The aim of this study was to examine the clinical relationship between the fracture morphology (spiral, oblique, transfer) of clavicle fractures that develop during delivery in newborns and BPI. We retrospectively reviewed all perinatal clavicle fractures diagnosed at our institution over 6 years.

RESULTS

The study included 55 newborn infants with perinatal clavicle fracture. Of these, 60% (n=33) were male. Right-side clavicle fractures were present in 56.4% (n=31) and shoulder dystocia was present in 58.2% (n=32) of the patients. Of the fracture localization of the patients, 85.5% (n=47) (Allman I) and 14.5% (n=8) (Allman II) were lateral. Allman type I fractures were not associated with increased BPI (P>0.05). It was observed that 40% (n=22) of the clavicle fractures were characterized by oblique morphology, 34.5% (n=19) of the fractures by spiral morphology, and 25.5% (n=14) of the fractures by transfer morphology. In all, 41.8% (n=23) of the sample also had BPI. Of the entire sample, 40% (n=22) most frequently showed oblique morphology fractures, whereas the patient group with BPI showed spiral morphology as the most common fracture, at a rate of 52.2% (n=10). After examining the relationship between fracture morphology and BPI, the study determined a statistically significant correlation between spiral and oblique morphology fractures and the development of BPI.

CONCLUSIONS

To our knowledge, our study is the first to examine the relationship between newborn clavicle fracture morphology and BPI. We think that they should be evaluated for increased BPI risk in newborn patients that have clavicle fractures with spiral and oblique morphology.

Brachial Plexus Birth Injuries

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

The Incidence of Pediatric Tibial Spine Fractures Is Greater and Peaks Later in Male Patients

Purpose

Methods

Results

Conclusions

Clinical Relevance

Brachial Plexus Birth Injuries: A Critical Analysis Review

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The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births.

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The gold standard for predicting the need for early intervention remains serial examination.

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Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers.

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Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.

Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis?

Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Team Approach: Management of Brachial Plexus Birth Injury

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.

Isolated neonatal clavicular fracture is a risk factor for future shoulder dystocia

Objective: Shoulder dystocia (SD) is a risk factor for neonatal clavicular fracture (CF). Previous SD is a known risk factor for subsequent SD. It is unknown whether an isolated neonatal CF (one that is not associated with SD) increases the risk of future SD. We aimed to investigate this question.Methods: A retrospective computerized database study conducted at Shaare Zedek Medical Center, a university-affiliated hospital, between 2005 and 2018. We included in the study all women that had a vaginal delivery without SD and had a subsequent vaginal delivery in our center between 2005 and 2018. Medical records of parturients who had a coded diagnosis of neonatal CF were retrieved. The first delivery with the neonatal diagnosis of an isolated CF was chosen as index delivery. Rates of SD at the subsequent delivery were assessed and compared between parturients with isolated neonatal CF (INCF) and parturients without neonatal CF or SD at the index delivery. To account for dependency between deliveries of the same individual parturient, we used generalized estimating equation (GEE) models.Results: We identified 39,601 parturients that met the inclusion criteria. During the study period, 519 parturients with a diagnosis of INCF that had at least one subsequent delivery were identified (1.3%). Overall, 3.9% of parturients with isolated CF (20/519) had subsequent SD, as compared to 0.5% of parturients without CF or SD at the index delivery (190/39082; p < .01). Previous diagnosis of INCF was found to be independently associated with SD in a subsequent delivery after controlling for known risk factors for SD (aOR = 6.41, 95% CI = 3.92-10.61). Previous diagnosis of an INCF was also found to be independently associated with a subsequent event of SD in all subsequent deliveries of the same individual parturient (aOR = 3.42, 95% CI = 2.26-5.18).Conclusion: Women with previous INCF have an increased risk for SD in subsequent deliveries. Intervention efforts directed at this particular subgroup of women should be applied, with special attention to potentially modifiable risk factors to minimize the risk for future SD.