Fractures are most often observed following breech delivery and/or shoulder dystopia in macrosomia infants.

Clavicular fracture

The clavicle is the most frequently fractured bone in the neonate during birth and most often is an unpredictable unavoidable complication of normal birth. Some correlation with birth weight, midforceps delivery, and shoulder dystocia exists. The infant may present with pseudoparalysis. Examination may reveal crepitus, palpable bony irregularity, and sternocleidomastoid muscle spasm. Radiographic studies confirm the fracture.

Healing usually occurs in 7-10 days. In order to decrease pain, arm motion may be limited by pinning the infant's sleeve to the shirt. Assess other associated injury to the spine, brachial plexus, or humerus.

Long bone fracture

Loss of spontaneous arm or leg movement is an early sign of long bone fracture, followed by swelling and pain on passive movement. The obstetrician may feel or hear a snap of fracture at the time of delivery. Radiographic studies of the limb confirm the diagnosis. Femoral and humeral shaft fractures are treated with splinting. Closed reduction and casting is necessary only when displaced. Watch for evidence of radial nerve injury with humeral fracture. Callus formation occurs, and complete recovery is expected in 2-4 weeks. In 8-10 days, the callus formation is sufficient to discontinue immobilization. Orthopedic consultation is recommended. Radiographic studies distinguish this condition from septic arthritis.

Epiphysial displacement

Separation of humeral or femoral epiphysis occurs through the hypertrophied layer of cartilage cells in the epiphysis. The diagnosis is made clinically based on the finding of swelling around the shoulder, crepitus, and pain when the shoulder is moved. Motion is painful, and the arm lies limp by the side. Because the proximal humeral epiphysis is not ossified at birth, it is not visible on radiography. Callus appears in 8-10 days and is visible on radiography.

Management consists of immobilizing the arm for 8-10 days. Fracture of the distal epiphysis is more likely to have a significant residual deformity than is fracture of the proximal humeral epiphysis.

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