A 3-hour-old girl is evaluated in the newborn nursery due to fussiness. The patient breastfed immediately after birth but afterward has been difficult to console. The father says, "Every time I pick her up she screams." The neonate was born at 41 weeks gestation via spontaneous vaginal delivery to a 30-year-old primigravida. The mother has type 1 diabetes mellitus, which was diagnosed at age 11 and is well controlled. She had unremarkable serologic testing in the first trimester and a negative rectovaginal culture for group B Streptococcus at 35 weeks gestation. The delivery was complicated by prolonged rupture of membranes of 21 hours. The neonate was vigorous at birth with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. She weighs 3.6 kg (7 lb 15 oz). Vital signs are within normal limits. Physical examination shows a quiet, alert girl in no distress. Auscultation of the chest is normal. Palmar grasp reflex is present and symmetric. The patient cries with passive movement of the left arm, and there is crepitus with edema over the left mid-clavicle. The presumed diagnosis is discussed with the parents. The mother says, "I can't believe this happened. I'm so worried. What is the next step?" Which of the following is the most appropriate response regarding management of this patient?
Neonatal displaced clavicular fracture | |
Risk factors |
|
Clinical features |
|
Diagnosis |
|
Treatment |
|
This patient has signs of a clavicle fracture (eg, pain with upper extremity movement, crepitus over clavicle). The clavicle is the most commonly fractured bone in newborns. Risk factors include macrosomia, shoulder dystocia, and device-assisted delivery (eg, forceps, vacuum). As in this case, however, many newborns with clavicle fracture do not have risk factors.
Examination findings include pain with passive movement of the ipsilateral upper extremity and crepitus or swelling over the clavicle. The Moro reflex may be asymmetric due to clavicular fracture or a concomitant brachial plexus injury. Brachial plexus palsy is diagnosed clinically by the presence of arm weakness in a given cervical nerve distribution, which is not present in this patient (Choice A).
A plain radiograph confirms the diagnosis of a fracture. Management includes gentle handling and parental reassurance. To prevent painful movement, the affected arm should be flexed 90 degrees at the elbow and pinned to the neonate's shirt. The fracture heals spontaneously over several weeks without sequelae. Surgery, physical therapy, and casting are therefore not indicated (Choices C, D, and E).
Educational objective:
Neonatal clavicular fractures can present with localized crepitus and irritability with passive motion of the ipsilateral upper extremity. Management is supportive, and there are no long-term sequelae.