clavicleAlthough clavicle fractures are relatively common during a vaginal delivery and can often self-resolve, an early diagnosis is preferable for a variety of reasons. As part of the 'Community Case' series in Journal of Family Health Care Magazine, Dr Siba Paul and consultant paediatric surgeon David Williamson explain why.

Injury during birth is a recognised cause of neonatal morbidity and mortality. Fracture of the clavicle is relatively common during a vaginal delivery. The incidence of fractured clavicle is between 0.4% and 2.9% of all newborns according to the latest study by the Journal of Bone & Joint Surgery.

Up to 40% of clavicle fractures may remain undetected while the baby is in hospital. Primary care health professionals, such as health visitors and community midwives, will come across these undiagnosed clavicle fractures either due to an incidental pick-up or being consulted by the parents because of concern regarding a lump over the collar bone or not moving the upper limb properly.

Case in Practice
We recently saw a case of newborn with a clavicle fracture which was detected during the neonatal examination. The baby was born by a normal vaginal delivery with no history of shoulder dystocia. The birth weight of the baby was 3.56 kg. The parents reported that the newborn was not moving the right upper limb properly.

Clavicle fracture in the newborn may be complete or incomplete (greenstick fracture) and in the latter may remain asymptomatic. The most common presentation is decreased movement of the ipsilateral arm. Clavicular fractures may be associated with an Erb’s palsy but it is uncommon and residual neurological deficits are rare. If this persists, specialist referral should be made. Examination of the clavicle may reveal crepitus, a palpable bony abnormality, a palpable spongy mass or discoloration over the fracture site. In a study of 1,661 term newborns with a clinical diagnosis of 24 clavicle fractures, 22 were confirmed by a radiograph or callous formation.

Diagnosis and management

The diagnosis of a neonatal clavicle fracture may be confirmed radiographically by an X-ray. Ultrasound examination may be a safer alternative to establish the diagnosis, but needs an experienced ultrasonographer. The fracture usually heals without any treatment in a few weeks and reassurance is all that is required for the parents. Clear documentation should be made in the child’s clinical notes, as it may have a medico-legal implication.

The differential diagnoses include humeral fracture, shoulder dislocation and brachial plexus injury. Neonatal clavicular fractures usually heal spontaneously with no deformity. Congenital pseudarthrosis of the clavicle may present as a newborn clavicle fracture and results from failed coalescence of the two primary ossification centres. This may present a diagnostic challenge and will need a referral to an orthopaedic specialist. 

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