Clavicular fracture in the newborn: Is fracture location a risk factor for obstetric brachial palsy?

Medial clavicle shaft fractures in children and adolescents: differences from adults and management

Clavicle fractures are a common injury in the pediatric and adolescent population. Most fractures are located in the middle third of the clavicle. There has been no information in the literature regarding the management of extra-physeal medial clavicle shaft fractures in this population. The objective of this study is to evaluate demographic and injury characteristics, management options and clinical outcomes of medial clavicle fractures in children and adolescents and differentiate them from those in adults. A retrospective review was performed at a single institution to identify patients with medial clavicle shaft fractures. Radiographs, clinical features and patient-reported outcomes (QuickDASH) were analyzed. Eight patients were identified with medial clavicle fractures. Two fractures could not be diagnosed on anteroposterior radiographs. Both operative (four patients) and nonoperative (four patients) treatment had excellent radiographic and clinical outcomes, irrespective of initial displacement. Compared to high-energy and life-threatening injuries in adults, these fractures in children and adolescents were sports-related and isolated fractures. Conservative treatment should be considered for medial clavicle fractures in children and adolescents. These fractures are distinct from their adult counterparts and do not lead to increased morbidity or mortality.

Obstetric fractures in caesarean delivery and risk factors as evaluated by paediatric surgeons

Introduction

Obstetric fractures usually occur after complicated births and are sent to paediatric orthopaedics for treatment and follow-up. Clavicle fractures represent the most common orthopaedic birth injury, involving approximately 0.2 to 3.5% of births.

Hypotheses

Caesarean delivery, elective or necessary, along with the type of presentation, may play a determinant role in the aetiology of obstetric fractures.

Materials and methods

We chose to do a retrospective study to determine possible risk factors for this type of injury that may manifest in either delivery. Our aim was to deepen our knowledge in order to have a better prediction and a better management of this condition. Data gathered included parity, gestity, type of delivery, presentation, shoulder dystocia, type of fracture, birth weight, and APGAR score.

Results

We followed 136 patients that were diagnosed with Allman type I clavicle fracture, 32 of them also having brachial plexus birth palsy (BPBP) type 1 (Duchenne-Erb). Natural birth with a pelvic presentation imposes a relative risk of 6.2 of associated pathology compared to cranial presentation. Caesarean delivery and cranial presentation increase the risk of related pathology by 5.04 compared to natural birth. Statistically, pelvic presentation is 5.54 times more likely to develop related pathology than cranial presentation. Type of delivery and presentation correlate with associated pathology of clavicle fractures.

Discussion and conclusion

Caesarean delivery brings risks for the newborn and should be practiced only when necessary. Predictive modeling in obstetrics in third-trimester evaluations may statistically predict risks of birth complications like fracture and BPBP.

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.

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.

Epidemiology and management of appendicular fractures occurring in neonatal intensive care patients

AIM

To describe the epidemiology and management of appendicular fractures occurring in the neonatal ICU in a large series of patients treated a single, quaternary care neonatal intensive care unit.

METHODS

Patients <1 years old with appendicular fractures treated from 2012 to 2016 at a quaternary-level NICU were identified. Bivariate testing compared fractures, work-up and management based on designated mechanism (presumed birth-related vs unknown). In patients with unknown mechanism, factors with potential fracture association were analysed in a descriptive fashion.

RESULTS

Eighty-five fractures (54 patients) were included. Mechanistic cohorts differed by birthweight (P < .001) and gestational age at birth (P < .001). Presumed birth-related fractures were more commonly upper extremity (P < .001), solitary (P = .001) and radiographically diagnosed in the acute state (<.001). The biochemical profile of the cohorts differed significantly. The prevalence of factors with potential fracture association was high in patients with unknown mechanism. Only one patient required surgery, while all others resolved with minimal orthopaedic intervention.

CONCLUSION

Findings indicate these injuries rarely require operative intervention and that two distinct injury profiles appear to exist based on fracture mechanism. Steroid use, ventilation use, diuretic use, nutritional supplementation and recent bedside procedures were common among patients without known fracture mechanism.

LEVEL OF EVIDENCE

Level III-Retrospective Cohort Study.

The relationship between the location of neonatal clavicular fractures and predisposing factors

BACKGROUND

The aim was to investigate the maternal and fetal predisposing factors of clavicle fracture locations in newborns.

METHODS

A retrospective evaluation was made of 77 clavicle fractures identified from a total of 33,480 live newborns between September 2016 and September 2018 at a single center in Turkey. Fractures were grouped according to the Allman classification: Group I mid third, Group II lateral distal third, Group III medial proximal third of the clavicle, respectively. Demographic features compared between the groups included maternal age, parity and height and infantile gestational age, gender, birth weight and length. Neonatal clinical features were also compared between the three groups and included mode of delivery, Apgar score, fracture laterality, time to diagnosis, mode of diagnosis, and presence of symptoms of brachial plexus palsy.

RESULTS

There were no statistically significant differences between the three groups when the demographic characteristics of the mothers and newborns were compared. In terms of clinical characteristics Group 3 contained a higher proportion of patients with symptoms of brachial plexus palsy than Group 1 (61.5% versus 22%, p = 0.017). There was no statistically significant difference between Groups 2 and 3 and Groups 1 and 2.

CONCLUSION

A significant association was found between the occurrence of brachial plexus palsy and fracture of the medial third of the clavicle (Allman type III).