Open access peer-reviewed chapter - ONLINE FIRST
Abstract
A neonatal fracture is a severe complication creating problems regarding diagnosis and appropriate management. Diagnosis from the neonatologist occasionally is difficult. A paediatric orthopaedic surgeon is required to evaluate the neonate, and confirm diagnosis and treatment. Clavicle fracture is the most common injury that must be differentiated occasionally from neonatal brachial plexus palsy. The clinical signs are crepitus, swelling, bony prominence, with the restriction of the movements of the arm. Occasionally, the fracture is diagnosed later. Clavicle pseudoarthrosis is a rare dysplasia. Fracture of the femur or the humerus presents with swelling, crepitus and deformity of the limb, creating difficulties in clothing, bathing and feeding. Most commonly are found in urgent caesarean delivery or complicated dystocia with over-weighted neonates. Bone fragility diseases (osteogenesis imperfecta, hypophosphatasia, arthrogryposis) are diagnosed from neonatal fractures. Conservative treatment with immobilization is the method of choice. Extremely rare is surgical treatment. Premature and low-weighted babies are in high risk to sustain fractures. Epiphyseal fractures of the distal femoral or humeral epiphysis are rare fractures, difficult to be diagnosed initially. They require immediate reduction to avoid permanent lesion of the growth plate. Fractures of forearm, tibia or vertebrae are extremely rare and associated with a bone fragility disease.
Keywords
- neonatal fracture
- perinatal femoral fracture
- perinatal humerus fracture
- fragile neonate bone
- premature and low weight neonates
- birth related fractures
1. Introduction
Neonatal fractures are extremely rare. Initial diagnosis is occasionally obscure and clinical signs of oedema, crepitus, and mainly discomfort of the neonate are the main symptoms that the neonatologist is evaluating. The incidence of neonatal fractures is reported to be less than 1 per 1000 births. In a previous report among 158,035 full term neonates, fracture was demonstrated in 1174 of them (0.74%). In a recent survey in UK, in the period 2000–2016, in 87,461 live births, 66 sustained a fracture, with the clavicle fracture being the most common, as found in 46 cases. This is a low incidence overall of 0.075% [1, 2]. Increased fetus weight and vaginal delivery with associated labor dystocia were initially reported as predisposing factors. But several reports of fractures with cesarean delivery (CS) are reported as well. Preterm with small for gestational age babies are in increased risk for a neonatal fracture. Multiple birth, breech delivery, increased maternal body weight are among the risk factors for a neonatal fracture. Neonatal fractures may present as the initial sign of underlying bone fragility. Neonatal fractures are occasionally diagnosed in uncomplicated labor. A neonatal fracture may also be diagnosed after discharge from the maternity hospital, usually found from the callus formation or the persistent discomfort of the neonate [3, 4, 5, 6, 7].
2. Clavicle fractures
Fractures of the clavicle are the most common neonatal fractures. They are usually found in vaginal delivery of an overweight neonate. Shoulder dystocia is a severe complication during birth and immediate action is required from the obstetrician in order to avoid respiratory disturbance of the neonate. The fracture of the clavicle reduces the shoulder tension and promotes the early delivery of the neonate. Otherwise the hyperextension of the neck may lead to severe brachial plexus palsy. A fracture of the clavicle in a neonate can be diagnosed without history of dystocia, most commonly after a cesarean delivery. Urgent cesarean births have a higher incidence of clavicle fractures. Delayed deliveries over 39 weeks of gestation are reported with a higher incidence of clavicle fracture and brachial plexus palsy [8, 9, 10, 11, 12, 13, 14].
The main clinical sign is the restricted Moro reaction sign (Moro (startle) reflex, arms abduct in response to sensation of falling) that is the reduced abduction and external rotation of the affected arm. This is the most common examination test that the neonatologist performs in the newborn. The newborn has active movements of the wrist and fingers and easy flexion of the elbow in the affected side. The newborn expresses discomfort and is crying while changing clothes or while moving the arm while breast feeding. Oedema in the clavicle region appears usually in the 2nd and 3rd day, with crepitus while examining the clavicle. The clavicle ossifies following intramembranous and not endochondral ossification. It produces early an enlarged callus that is remodeled and the signs of the clavicle fracture are eliminated by the 3d month. Clinical signs are often obscure early and the family notices the presence of the enlarged callus in the clavicle region after a week time. There are normal movements of the affected side and even the Moro sign may have been reported as normal.
Radiological examination confirms the diagnosis and is mainly performed for the medico legal issues in case that there are associated lesions as brachial plexus palsy. Radiological examination is not always required since in typical cases we can reassure the parents for the benign course of the clavicle fracture. Ultrasound examination from an experienced radiologist can assist by confirming the disruption of the cortical continuity. There is no specific treatment that is required for this fracture. We inform the nurses and the family for the appropriate dressing and bathing of the neonate and to avoid the elevation of the affected arm. In a few days the neonate is moving the arm without discomfort. The arm is kept in the relaxed position with the elbow in 90 degrees of flexion, in the anterior part of the body (Figures 1 and 2).
Figure 1.
Fracture of left clavicle.
Figure 2.
Unable to perform the Moro reaction with the left arm.
The presence of an enlarged lump on the right clavicle of a baby, after several months, must be differentiated from congenital clavicle pseudoarthrosis. This is an extremely rare dysplasia, usually diagnosed in the preschool age, as it is a painless lump in the clavicle. Appropriate imaging with X-ray and CT scan confirms the diagnosis of the congenital pseudoarthrosis. There is absence of history of birth trauma. This dysplasia can be treated surgically with appropriate excision and plating, mainly for esthetic reasons. A new born with bilateral pseudoarthrosis of the clavicle that presented spontaneous recovery has been reported [15, 16] (Figures 3 and 4).
Figure 3.
X-ray-s of bilateral clavicle pseudoarthrosis with spontaneous union at a year time.
Figure 4.
X-ray-s of bilateral clavicle pseudoarthrosis with spontaneous union at a year time.
3. Neonatal femoral fractures
A neonatal femoral fracture is a rare but severe complication of the birth. The reported incidence is about 0.1/10000 births [17]. Although was believed that elective cesarean delivery would eliminate the incidence of birth trauma, this is not confirmed, and several reported neonatal femoral fractures are associated with CS. Femoral fracture in CS is an extremely rare complication. Urgent CS, increased birth weight, breech position, fibromatosis of the uterus, inadequate uterine relaxation, inadequate incision in the uterine segment are reported as predisposing factors for femoral fractures in CS [1, 2, 3, 4, 5, 17, 18, 19, 20, 21].
The obstetrician may feel the cracking sound and observe the pathological mobility of the femur, but this is uncommon. The examining pediatrician and the nurse will notice the swelling of the fractured femur and the abnormal shape and movements of the leg. The neonate is crying and dressing is extremely painful. Suspicion for the fractured femur may not be noticed until the 2nd and 3rd day of the life. Mother will report the permanent irritation of the neonate, the difficulties for breast feeding, since every movement causes crying. A case of a spiral femur fracture diagnosed 9 days postpartum, after an elective CS for the breech presentation has been reported [22].
Diagnosis is confirmed with appropriate X-ray examination. Fractures commonly affect the proximal third and the diaphysis of the femur. The proximal part is shifted in flexion and abduction, due to the imbalance of the muscle action (Figures 5 and 6).
Figure 5.
The initial X-ray with a spiral fracture, with flexion and abduction of the proximal part.
Figure 6.
Initial X-ray of the fractured femur with severe displacement in flexion and abduction of the proximal part. Treatment provided was skin traction with Bryant’s method, for both legs.
Treatment is provided with appropriate skin traction, either with Bryant’s traction (both limbs suspended in the air vertically at 90°) or with simple skin traction. We use bilateral traction, with hips flexed in 90° and the buttock in a distance from the bed. We use simple skin traction in fractures in the middle third of the femur. Breast feeding becomes difficult, as the mother must lie in an uncomfortable position and the neonate is trying to feed by flexing the head, while it is in the traction. With patience and assistance from the nurse, this can be achieved. In premature children that must remain incubated or in the box, this traction is applied in their box [23, 24].
Fractures are united with excessive callus formation (Figure 7).
Figure 7.
Massive callus formation of the fractured right femur, in 2 months.
Usually a period of 2–3 weeks in traction is adequate to remove the traction. Use of Pavlik harness has also been recommended, with appropriate balance of the fractured parts of the femur but is not a stable position mainly during the first week. Use of the harness requires frequent adjustments and the nursing stuff is unfamiliar with these corrections. We recommend the use of the harness after at least 10 days of traction, with caution, since the oversight of a pediatric orthopedic surgeon is of great importance in order to retain the appropriate reduction. Alternative methods of immobilization have been reported. Strapping the thigh to abdomen or the use of a hip spica are also described methods of immobilization [18]. We recommend for the neonate with a fractured femur the use of skin traction with Bryant’s method as the safest and comfortable treatment. We have treated 5 neonates with femoral fractures, using skin traction over the past 20 years and we report very good results. We have not observed any rotational deviations and no leg length discrepancy in the first years of life.
The natural history is the early remodeling of the fracture. The child is observed up the age of 2–3 years old, to ensure the final leg length discrepancy and the appropriate shape of the femur. During the treatment period with skin traction it is of paramount importance to correct possible severe external rotation of the femur, since rotational deformities are not corrected with the remodeling process (Figures 8 and 9).
Figure 8.
Excessive callus formation at 3 weeks of the fractured neonate femur.
Figure 9.
At 1 year there is complete remodeling of the fractured left femur.
Surgical treatment is not recommended for the neonatal fracture. A case from Italy was reported using an external fixator for a neonate with lumbar myelomeningocele and fractured femur [25]. In case that fractured parts show severe angulations that must be corrected with appropriate change of the traction. We have treated an extremely rare case of a neonate that the fractured segment was caught under the skin. Despite the use of Bryant’s traction and appropriate manipulation this was not corrected. We performed a minimal skin incision to reduce the fracture by splinting the muscles and stabilized temporally the segments with a K-wire and hip spica. The neonate was closely observed with appropriate support from neonatologists. He had an uneventful recovery (Figures 10 and 11).
Figure 10.
Severe displacement and entrapment of the proximal part under the skin, despite use of Gallow’s traction.
Figure 11.
Minimal incision, release of muscles and reduction, stabilized with a K-wire and hip spica. Apparent callus formation in a week time after reduction.
4. Fragility neonatal fractures
Fractured neonatal femur may be the initial sign of an underlying disease with bone fragility. Osteogenesis imperfecta (OI) is a heterogeneous connective tissue disorder characterized from severe osteoporosis. The synthesis of collagen type I is disrupted due to pathogenic genes. There is low bone mass with bone fragility that leads to recurrent fractures of the axial skeleton and the long bones resulting in severe deformities. Although there have been reported to be more than 20 types of gene heterogeneity of OI, the clinical phenotype classification of Silence remains a valuable description of the severity of the disorder. The lethal form (type 2) presents with intrauterine fractures diagnosed with the prenatal ultrasonography. Long bones are described with bowing and shortening. X-ray examination in the neonate reveals several fractures, occasionally affecting the ribs as well. Femoral or tibial fractures are either spiral or transverse fractures. Type 3 OI presents with fractures without history of urgent manipulation of the neonate because of dystocia. On x-ray examination the bones are deformed and there is cortical thinning [26, 27, 28] (Figure 12).
Figure 12.
Initial fracture of the left femur, following an uncomplicated normal vaginal delivery. Bowing and sclerosis of the right femur is noticed. The girl was diagnosed with osteogenesis imperfecta type 3.
With minor handling of the neonate, a crack may be felt and a new fracture may be diagnosed. There are clinical features with the prominent frontal bone, the short height of the neonate, and the ligamentous laxity. Child abuse must be ruled out in the presence of multiple fractures that are at different times of callus formation. Fractures found in clavicles, long bones or vertebrae are strong indications of the underlying bone fragility [29]. There are several metabolic diseases affecting the neonate that present with neonatal fractures. Disturbances of the calcium and phosphate metabolism as in phosphatasia and rickets are among the rare but severe diseases that are diagnosed through neonatal fractures, affecting both long bones and vertebrae and ribs. Appropriate laboratory investigations from neonatologists and endocrine pediatricians with genetic investigations, can provide an accurate diagnosis [30, 31, 32, 33, 34]. Treatment of neonatal fractures that are due to metabolic diseases follows the same principles as the femoral fractures of normal neonates with the use of Gallows traction. Modifications for use of traction in the neonatal box are described. Appropriate medical treatment is essential in order to reduce the number of fractures that may follow. Gene therapy is today the most promising treatment method for these severe forms. Stem cells therapy in the prenatal period has been reported [35].
Bilateral neonatal femoral fractures have been reported in a neonate with multiple congenital anomalies, with joint stiffness, similar to arthrogryposis. Arthrogryposis may be prenatally detected in a fetus with reduced mobility. It is important for the obstetrician to be informed of the joint stiffness in order to avoid vigorous movements that may lead to neonatal fractures [36] (Figures 13 and 14).
Figure 13.
Bilateral fractured femur in a neonate with complex stiff joints. Casts were applied for the club feet deformities. Treatment provided with Gallows traction. X-ray with united femoral fractures.
Figure 14.
Bilateral fractured femur in a neonate with complex stiff joints. Casts were applied for the club feet deformities. Treatment provided with Gallows traction. X-ray with united femoral fractures.
5. Metabolic bone disease in premature neonates
Premature neonates apart from the problems of low birth weight and respiratory disturbances, are associated with impaired mineralization of the bones. Several metabolic disturbances that include hypocalcemia, hypophosphatemia, and secondary hyperthyroidism must be ruled out in order to improve bone strength. Spontaneous fractures and deformities may appear and the nursing stuff and neonatologists must be very careful in the daily treatment of these premature neonates [37, 38, 39, 40, 41, 42].
6. Distal femoral epiphysis lesion
A rare type of neonatal femoral fracture is the epiphysiolisthesis of the distal femoral epiphysis. The knee joint presents with effusion, there is limited movement of the affected limb, like a type of pseudoparalysis. The neonate is restless and bathing and dressing are difficult because of the reactions of the neonate. Diagnosis is obscure and septic arthritis of the neonate must be differentiated from epiphysiolisthesis. The distal femoral epiphysis ossification nucleus appears in infancy, but it is a small one and separation is not easily appearent on plain X-rays. Plain X-rays may appear with a minimal disruption of the metaphyseal corner. Ultrasound examination is helpful but cannot confirm diagnosis, as the fluid collection of the effusion may be a sign of infection. MRI examination will reveal the translation of the epiphysis. On MRI the hematoma is well demarcated with the separation of the epiphysis in the growth plate (Figures 15–17).
Figure 15.
Distal femoral epiphysiolisthesis Salter type 1, with calcification from the periosteal elevation. MRI demonstrates the hematoma and the periosteal elevation.
Figure 16.
Distal femoral epiphysiolisthesis Salter type 1, with calcification from the periosteal elevation. MRI demonstrates the hematoma and the periosteal elevation.
Figure 17.
Distal femoral epiphysiolisthesis Salter type 1, with calcification from the periosteal elevation. MRI demonstrates the hematoma and the periosteal elevation.
The distal femoral epiphysis is the most important for the proper growth of the limb, so the lesion must be diagnosed early in order to reduce the epiphysis. It is a Salter Harris type 1 or 2 lesion. The limb is immobilized in a light cast, incorporating the foot. If properly reduced, then growth of the limb may not be affected. The neonate must be followed for the next years to confirm the leg length equality. There have been reported cases with reduction and stabilization using K-wires. These injuries may create severe leg length discrepancy (LLD) and it is important for them to be evaluated by a pediatric orthopedic surgeon [43, 44, 45, 46, 47, 48].
7. Humerus fractures
Fractures of the humerus are most commonly found in cases of urgent CS with the inappropriate handling of the fetus in an effort to complete the delivery and ensure proper respiration of the baby. Similar to femoral shaft fractures in the lower extremity, clinical signs are the absence of movement of the arm, angulations, oedema, and crepitus. Because of the decreased musculature of the humerus, this fracture is more easily diagnosed, as during bathing or dressing the neonate, the arm is angulating and the neonate is crying.
X-ray examination reveals the shaft fracture of the humerus
Figure 18.
Fracture of the left humerus after an emergency CS delivery.
Figure 19.
Fracture of the right humerus and treatment with appropriate strapping with Velpeau type of immobilization.
Figure 20.
An isolated left radial nerve palsy. Note the flexion of the left elbow with the shoulder movement, while the wrist and fingers are not extending.
There are various methods for appropriate immobilization of the humerus fracture, but in case of a transverse fracture it is difficult to obtain a stable immobilization. Use of a U slab is uncomfortable and we prefer a Velpeau type of immobilization that is easily accepted and comfortable, enabling the proper breastfeeding of the neonate (Figure 20). It is important to achieve proper rotational alignment of the fracture since remodeling of the rotational deformities is poor. Excessive callus formation is found by the end of the 2nd week, and gradual mobilization is permitted. Humerus fractures may also present as the initial signs of metabolic disease and OI [29] (Figure 21).
Figure 21.
Fracture left humerus, after a CS delivery, as the first sign of Osteogenesis imperfecta.
8. Fracture of the distal humerus epiphysis
An extremely rare injury is the epiphysiolisthesis of the distal humerus epiphysis that is commonly diagnosed with delay. Clinical signs are swelling of the elbow, with increased anxiety of the neonate and reduced mobility of the affected arm. The differential diagnosis includes neonatal septic arthritis and brachial plexus palsy. Appropriate clinical examination is essential for the correct diagnosis. Radiological examination reveals signs of possible elbow dislocation (Figure 22). There is malalignment of the humerus with the proximal part of the radius and ulna. The distal humerus epiphysis is not ossified and cannot be found separated from the metaphysic on X-ray. The medical history of possible forceful handling of the arm during delivery is of importance. Ultrasound examination is helpful by revealing the diffuse hematoma and the separation of the chondral epiphysis. MRI has been used in order to make the diagnosis. The distal epiphysis appears separated from the metaphysis of the humerus.
Figure 22.
Distal humerus epiphysiolisthesis appears on X-rays as an elbow dislocation.
Appropriate reduction in the first 2–4 days is essential in order to restore the anatomy and appropriate elbow function. Reduction is easily performed in the first 1–2 days with an impressive resolution of the symptoms. The elbow becomes less swollen and the relief of the neonate appears almost immediately. Proper casting with a brace is important for a period of 2 weeks. Reduction must be performed under anesthesia, using C-arm and possibly with the addition of an arthrogram, in order to reassure the accurate reduction. Arthrogram in the neonate elbow is hard to be achieved with accuracy but in cases of a fracture with the hematoma of the joint that is swollen, it can be performed. Callus formation from the periosteal elevation in neonates is apparent early and reduction is not advised later than a period of a week.
K-wire stabilization is reported in cases of instability of the epiphysiolisthesis, but Salter type 1 and 2 are usually stable after appropriate reduction and cast immobilization is adequate. Remodeling of the humerus has been reported even in cases that the epiphysiolisthesis was diagnosed later and without reduction. But this extremely rare injury must be treated with adequate reduction in the initial first days [56, 57, 58, 59, 60, 61, 62, 63, 64, 65].
9. Fractures of forearm
Fracture of the forearm is extremely rare and may be a sign of the underlying bone fragility, with similar fractures in the femur or humerus. Child abuse must be ruled out. Extremely rare is the report of a constriction band in the forearm with fracture of the underlying radius and ulna, with severe compromise of the vascularity of the forearm. Pseudorarthrosis of the radius or ulna as signs of neurofibromatosis are rarely diagnosed in the neonatal period. Hyperostosis of the forearm (Caffeys disease) is among the extremely rare cases with x-ray similar to neonatal fracture [66, 67, 68, 69, 70] (Figures 23 and 24).
Figure 23.
Hyperostosis of the forearm (Caffey disease). Initial X-ray with periosteal reaction and plastic deformation of the radius and ulna on the right side, while the left forearm is normal. The radiological appearance at 1 year, showing widening of the forearm bones.
Figure 24.
Hyperostosis of the forearm (Caffey disease). Initial X-ray with periosteal reaction and plastic deformation of the radius and ulna on the right side, while the left forearm is normal. The radiological appearance at 1 year, showing widening of the forearm bones.
10. Fractures of the tibia
These fractures are also extremely rare and are found in combination with fractures of the femur or humerus. Underlying bone fragility is suspected and investigations for possible OI or rickets must be performed. Neonate abuse syndrome must also be verified. We have followed a neonate that sustained fractures of the femur and tibia during birth after having a normal uncomplicated vaginal delivery. At the age of 2 years there is only short stature, without underlying metabolic disease (Figures 25–27).
Figure 25.
Multiple fractures of femur (right with callus formation, spiral left femoral fracture and tibia left). X-rays at birth and at 3 months. At the age of 2 yrs, there are no more fractures reported. The toddler is low height.
Figure 26.
Multiple fractures of femur (right with callus formation, spiral left femoral fracture and tibia left). X-rays at birth and at 3 months. At the age of 2 yrs, there are no more fractures reported. The toddler is low height.
Figure 27.
Multiple fractures of femur (right with callus formation, spiral left femoral fracture and tibia left). X-rays at birth and at 3 months. At the age of 2 yrs, there are no more fractures reported. The toddler is low height.
Metaphyseal greenstick type of fracture may be found as a result of vigorous handling of the leg of the neonate. They are differentiated from cases of fibrocartilaginous bowing that are usually found during the standing period of the infant. Constriction band syndrome with tibia and fibula fracture has also been reported. Congenital pseudoarthrosis of the tibia or fibula is diagnosed rarely in the neonatal period as part of the neurofibromatosis, presenting with anteromedial bowing. Congenital posterolateral bowing of the leg is a congenital benign deformity that is not correlated with a fracture [29, 66, 71, 72, 73].
11. Vertebral fractures
Severe spinal lesions affecting the cervical spine are extremely rare and affecting mainly the spinal cord and not the vertebrae. There are severe lesions associated with paralysis and they are usually lethal. Fractures of the vertebrae are found in neonates in severe lethal cases of OI and phosphatasia [74, 75, 76, 77].
12. Conclusion
Neonatal fractures are reported affecting all parts of the skeleton. Their incidence is increased in cases of difficult labor with an overweight neonate. Cesarean delivery in an emergency is associated with higher incidence of long bone fractures. Neonates with an underlying disease with bone fragility sustain neonatal fractures. Fractures may also appear in uncomplicated normal labor.
Clavicle fractures are the most common and their management is appropriate handling of the neonate. Callus formation that is diagnosed later as a prominence in the clavicular area is often the main symptom. Fractures of the femur and humerus are severe complications that require appropriate treatment from a pediatric orthopedic surgeon. Diseases with bone fragility must be ruled out. Premature babies with low birth weight are at increased risk to sustain fractures. Diagnosis of epiphysiolisthesis of the distal femur and humerus is extremely difficult and appropriate reduction is essential for the management. Neonatal fractures are complications of the labor that occasionally lead to severe medicolegal problems.
References
- 1.
Groenendaal F, Hukkelhoven C. Fractures in full-term neonates. Nederlands Tijdschrift voor Geneeskunde. 2007; 151 (7):424 - 2.
Rehm A, Promod P, Ogilvy-Stuart A. Neonatal birth fractures: A retrospective tertiary maternity hospital review. Journal of Obstetrics and Gynaecology. 2020; 40 (4):485-490. DOI: 10.1080/01443615.2019.1631770 - 3.
Högberg U, Fellman V, Thiblin I, Karlsson R, Wester K. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures. Acta Paediatrica. 2020; 109 (10):2040-2048. DOI: 10.1111/apa.15217 - 4.
Gupta R, Cabacungan ET. Neonatal birth trauma: Analysis of yearly trends, risk factors, and outcomes. The Journal of Pediatrics. 2021; 238 :174-180.e3. DOI: 10.1016/j.jpeds.2021.06.080 - 5.
Ariyawatkul T, Worawuthangkul K, Chotigavanichaya C, Kaewpornsawan K, Chalayon O, Eamsobhana P. Potential risk factors for birth fractures: A case-control study. International Orthopaedics. 2017; 41 (11):2361-2364. DOI: 10.1007/s00264-017-3600-5 - 6.
Williams BA, Makarewich CA, Montoya-Williams DC, Krakow A, Lioy J, Horn BD. Epidemiology and management of appendicular fractures occurring in neonatal intensive care patients. Acta Paediatrica. 2021; 110 (2):489-494. DOI: 10.1111/apa.15430 - 7.
Bhat BV, Kumar A, Oumachigui A. Bone injuries during delivery. Indian Journal of Pediatrics. 1994; 61 (4):401-405. DOI: 10.1007/BF02751901 - 8.
Tsai A, Grant PE, Warfield SK, Ou Y, Kleinman PK. Deep learning of birth-related infant clavicle fractures: A potential virtual consultant for fracture dating. Pediatric Radiology. 2022; 52 (11):2206-2214. DOI: 10.1007/s00247-022-05380-0 - 9.
Asena M, Akelma H, Ziyadanoğulları MO. The relationship between the location of neonatal clavicular fractures and predisposing factors. Journal Neonatal and Perinatal Medicine. 2020; 13 (4):507-511. DOI: 10.3233/NPM-190321 - 10.
Mumtaz Hashmi H, Shamim N, Kumar V, Anjum N, Ahmad K. Clavicular fractures in newborns: What happens to one of the commonly injured bones at birth? Cureus. 2021; 13 (9):e18372. DOI: 10.7759/cureus.18372 - 11.
Fadell M, Miller A, Trefan L, Weinman J, Stewart J, Hayes K, et al. Radiological features of healing in newborn clavicular fractures. European Radiology. 2017; 27 (5):2180-2187. DOI: 10.1007/s00330-016-4569-y - 12.
Kekki M, Salonen A, Koukkula T, Laivuori H, Tihtonen K, Huttunen TT. 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. Birth. 2022; 00 :1-10. Jun 23. DOI: 10.1111/birt.12662 - 13.
Choi HA, Lee YK, Ko SY, Shin SM. Neonatal clavicle fracture in cesarean delivery: Incidence and risk factors. The Journal of Maternal-Fetal & Neonatal Medicine. 2017; 30 (14):1689-1692. DOI: 10.1080/14767058.2016.1222368 - 14.
Gandhi RA, DeFrancesco CJ, Shah AS. The association of clavicle fracture with brachial plexus birth palsy. The Journal of Hand Surgery. 2019; 44 (6):467-472. DOI: 10.1016/j.jhsa.2018.11.006 - 15.
Laliotis NA, Chrysanthou C, Anastasopoulos N. Spontaneous union of bilateral congenital pseudoarthrosis of the clavicle, in a baby. Journal of Clinical Orthopoedic Trauma. 2020; 11 (2):314-316. DOI: 10.1016/j.jcot.2019.04.008 - 16.
Fontoura-Matias J, Vilan A. Clavicle lump: Not always a fracture - A case of congenital pseudoarthrosis. Pediatrics International. 2021; 63 (12):1544-1545. DOI: 10.1111/ped.14924 - 17.
Pavone V, Vescio A, Montemagno M, de Cristo C, Lucenti L, Pavone P, et al. Perinatal femoral fracture: A ten-year observational case series study. Children (Basel). 2020; 7 (10):156. DOI: 10.3390/children7100156 - 18.
Kancherla R, Sankineani SR, Naranje S, Rijal L, Kumar R, Ansari T, et al. Birth-related femoral fracture in newborns: Risk factors and management. Journal of Children Orthopedics. 2012; 6 (3):177-180. DOI: 10.1007/s11832-012-0412-4 - 19.
Basha A, Amarin Z, Abu-Hassan F. Birth-associated long-bone fractures. International Journal of Gynecologic Obstetrics. 2013; 123 (2):127-130. DOI: 10.1016/j.ijgo.2013.05.013 - 20.
von Heideken J, Thiblin I, Högberg U. The epidemiology of infant shaft fractures of femur or humerus by incidence, birth, accidents, and other causes. BMC Musculoskeletal Disorders. 2020; 21 (1):840. DOI: 10.1186/s12891-020-03856-4 - 21.
Kellner KR. Neonatal fracture and cesarean section. American Journal of Diseases of Children. 1982; 136 (9):865. DOI: 10.1001/archpedi.1982.03970450107027 - 22.
Kanai Y, Honda Y, Honda T, Sanpei M. Delayed birth-related femur fracture after cesarean section: A case report. AJP Reports. 2018; 8 (3):e158-e160. DOI: 10.1055/s-0038-1667190 - 23.
Matthews JJ, Cox PJ. Gallow’s traction in an incubator for treatment of neonatal femoral fracture. Annals of the Royal College of Surgeons of England. 2008; 90 (1):74-75. DOI: 10.1308/rcsann.2008.90.1.74 - 24.
Frik S. Management of birth-associated subtrochanteric femur fractures. Acta Orthopaedica Belgica. 2016; 82 (4):850-853 - 25.
D'Andrea L, Catena N. Femural shaft fracture in a newborn infant treated with axial external fixator: A case report. Journal of Pediatric Orthopedics. 2008; 28 (1):17-19. DOI: 10.1097/bpo.0b013e31815b4dea - 26.
Bellur S, Jain M, Cuthbertson D, Krakow D, Shapiro JR, Steiner RD, et al. Cesarean delivery is not associated with decreased at-birth fracture rates in osteogenesis imperfecta. Genetics in Medicine. 2016; 18 (6):570-576. DOI: 10.1038/gim.2015.131 - 27.
Cubert R, Cheng EY, Mack S, Pepin MG, Byers PH. Osteogenesis imperfecta: Mode of delivery and neonatal outcome. Obstetrics and Gynecology. 2001; 97 (1):66-69. DOI: 10.1016/s0029-7844(00)01100-5 - 28.
Tournis S, Dede AD. Osteogenesis imperfecta - A clinical update. Metabolism. 2018; 80 :27-37. DOI: 10.1016/j.metabol.2017.06.001 - 29.
Bayram S, Mert L, Anarat FB, Chodza M, Ergin ÖN. A newborn with multiple fractures in osteogenesis imperfecta: A case report. Journal of Orthopedic Case Report. 2018; 8 (3):71-73. DOI: 10.13107/jocr.2250-0685.1116 - 30.
Hackley L, Merritt L. Osteogenesis imperfecta in the neonate. Advances in Neonatal Care. 2008; 8 (1):21-30. DOI: 10.1097/01.ANC.0000311013.71510.41 - 31.
Botor M, Fus-Kujawa A, Uroczynska M, Stepien KL, Galicka A, Gawron K, et al. Osteogenesis imperfecta: Current and prospective therapies. Biomolecules. 2021; 11 (10):1493. DOI: 10.3390/biom11101493 - 32.
Rao R, Cuthbertson D, Nagamani SCS, Sutton VR, Lee BH, Krischer J, et al. Pregnancy in women with osteogenesis imperfecta: Pregnancy characteristics, maternal, and neonatal outcomes. American Journal of Obstetetics and Gynecology MFM. 2021; 3 (4):100362. DOI: 10.1016/j.ajogmf.2021.100362 - 33.
Sillence DO, Morley K, Ault JE. Clinical management of osteogenesis imperfecta. Connective Tissue Research. 1995; 31 (4):S15-S21. DOI: 10.3109/03008209509116827 - 34.
Deguchi M, Tsuji S, Katsura D, Kasahara K, Kimura F, Murakami T. Current overview of osteogenesis imperfecta. Medicina (Kaunas, Lithuania). 2021; 57 (5):464. DOI: 10.3390/medicina57050464 - 35.
Götherström C, David AL, Walther-Jallow L, Åström E, Westgren M. Mesenchymal stem cell therapy for osteogenesis imperfecta. Clinical Obstetrics and Gynecology. 2021; 64 (4):898-903. DOI: 10.1097/GRF.0000000000000656 - 36.
Laliotis N, Tsoni K, Konstantinidis P, Agakidou E, Chrysanthou C. Bilateral femoral fractures during birth, in a neonate with malformation complex with stiffness. Clinical Case Report. 2020; 8 (7):1230-1233. DOI: 10.1002/ccr3.2877. - 37.
Chinoy A, Mughal MZ, Padidela R. Metabolic bone disease of prematurity: Causes, recognition, prevention, treatment and long-term consequences. Achieves of Diseases Child Fetal Neonatal Edition. 2019; 104 (5):F560-F566. DOI: 10.1136/archdischild-2018-316330 - 38.
Rayannavar A, Calabria AC. Screening for metabolic bone disease of prematurity. Seminars in Fetal Neonatal Medicine 2020; 25 (1):101086. 10.1016/j.siny.2020.101086 - 39.
Michaud J, Luu TM, LeBlanc JC, Healy-Profitós J, Ayoub A, Auger N. Preterm birth and the future risk of orthopedic fracture. Pediatric Research. 2020; 88 (3):466-472. DOI: 10.1038/s41390-020-0771-3 - 40.
Chacham S, Pasi R, Chegondi M, Ahmad N, Mohanty SB. Metabolic bone disease in premature neonates: An unmet challenge. Journal of Clinical Research Pediatric Endocrinology. 2020; 12 (4):332-339. DOI: 10.4274/jcrpe.galenos.2019.2019.0091 - 41.
Schachinger F, Farr S. The effects of preterm birth on musculoskeletal health-related disorders. Journal of Clinical Medicine. 2021; 10 (21):5082. DOI: 10.3390/jcm10215082 - 42.
Nunes ME. In: Adam MP, Everman DB, Mirzaa GM, Pagon RA, Wallace SE, LJH B, Gripp KW, Amemiya A, editors. Hypophosphatasia. Seattle (WA): University of Washington; 2007 - 43.
Laliotis N, Kapetanakis S, Gkasdaris G, Konstantinidis P, Karoutsou R, Chourmouzi D, et al. Salter-Harris type II fracture of the distal femur in a newborn: Acute anatomic imaging alterations after labor dystocia. Clinical Case Report. 2019; 7 (7):1450-1451. DOI: 10.1002/ccr3.2149 - 44.
Franco A, Chaturvedi A. Neonatal distal femoral physeal injury secondary to mechanical trauma of birth: A case report. Clinical Imaging. 2018; 51 :65-67. DOI: 10.1016/j.clinimag.2018.02.006 - 45.
Eliahou R, Simanovsky N, Hiller N, Simanovsky N. Fracture-separation of the distal femoral epiphysis in a premature neonate. Journal of Ultrasound in Medicine. 2006; 25 (12):1603-1605. DOI: 10.7863/jum.2006.25.12.1603 - 46.
Banagale RC, Kuhns LR. Traumatic separation of the distal femoral epiphysis in the newborn. Journal of Pediatric Orthopedics. 1983; 3 (3):396-398. DOI: 10.1097/01241398-198307000-00024 - 47.
Ozturk M, Yurtbay A, Keskin D, Polat AV, Selcuk MB. Subperiosteal hemorrhage due to a distal femoral physeal fracture in a neonate. North Clinical Istanbul. 2018; 6 (3):312-314. DOI: 10.14744/nci.2018.26566.article - 48.
Wu X, Xia J, Li J, Sun J, Shen X. Distal femoral physeal fractures after neonatal osteomyelitis: A case report. Medicine (Baltimore). 2019; 98 (18):e15396. DOI: 10.1097/MD.0000000000015396 - 49.
Goyal ND, Pahwa AH, Rathod J, Jeyaraman M, Jain S, Dungarwal S. Diaphyseal fracture of the humerus during elective cesarean section - A rare case report. Journal of Orthopedic Case Report. 2021; 11 (6):10-13. DOI: 10.13107/jocr.2021.v11.i06.2236 - 50.
Canpolat FE, Köse A, Yurdakök M. Bilateral humerus fracture in a neonate after cesarean delivery. Archives of Gynecology and Obstetrics. 2010; 281 (5):967-969. DOI: 10.1007/s00404-009-1256-0 - 51.
Kaya B, Daglar K, Kirbas A, Tüten A. Humerus diaphysis fracture in a newborn during vaginal breech delivery. Obstetrics and Gynecology. 2015; 2015 :489108. DOI: 10.1155/2015/489108 - 52.
Rahul P, Grover AR, Ajoy SM. Bilateral humerus and right femur fracture in a newborn after cesarean section for breech presentation in a twin pregnancy: A very rare case report. Journal of Orthopedic Case Report. 2017; 7 (1):9-11. DOI: 10.13107/jocr.2250-0685.664 - 53.
Sherr-Lurie N, Bialik GM, Ganel A, Schindler A, Givon U. Fractures of the humerus in the neonatal period. The Israel Medical Association Journal. 2011; 13 (6):363-365 - 54.
Kumar N. Neonatal humerus shaft fracture appropriate treatment method. Medical Journal, Armed Forces India. 2005; 61 (2):210. DOI: 10.1016/S0377-1237(05)80049-8 - 55.
Mahapatra SK, Jangira V, Kalra M. Neonatal radial nerve palsy associated with humerus fracture: Is the fracture to be blamed? Orthopaedic Surgery. 2014; 6 (2):162-164. DOI: 10.1111/os.12106 - 56.
Gigante C, Kini SG, Origo C, Volpin A. Transphyseal separation of the distal humerus in newborns. Chinese Journal of Traumatology. 2017; 20 (3):183-186. DOI: 10.1016/j.cjtee.2017.04.003 - 57.
Malik S, Khopkar SR, Korday CS, Jadhav SS, Bhaskar AR. Transphyseal injury of distal humerus: A commonly missed diagnosis in neonates. Journal of Clinical Diagnostic Research. 2015; 9 (11):SD01-SD02. DOI: 10.7860/JCDR/2015/11619.6715 - 58.
Patil MN, Palled E. Epihyseal separation of lower end humerus in a neonate-diagnostic and management difficulty. Journal of Orthopedic Case Report. 2015; 5 (4):7-9. DOI: 10.13107/jocr.2250-0685.332 - 59.
Kamaci S, Danisman M, Marangoz S. Neonatal physeal separation of distal humerus during cesarean section. American Journal of Orthopedic. 2014; 43 (11):E279-W281 - 60.
Supakul N, Hicks RA, Caltoum CB, Karmazyn B. Distal humeral epiphyseal separation in young children: An often-missed fracture-radiographic signs and ultrasound confirmatory diagnosis. AJR. American Journal of Roentgenology. 2015; 204 (2):W192-W198. DOI: 10.2214/AJR.14.12788 - 61.
Jacobsen S, Hansson G, Nathorst-Westfelt J. Traumatic separation of the distal epiphysis of the humerus sustained at birth. Journal of Bone and Joint Surgery. British Volume (London). 2009; 91 (6):797-802. DOI: 10.1302/0301-620X.91B6.22140 - 62.
Tharakan SJ, Lee RJ, White AM, Lawrence JT. Distal humeral epiphyseal separation in a newborn. Orthopedics. 2016; 39 (4):e764-e767. DOI: 10.3928/01477447-20160503-01 - 63.
Sabat D, Maini L, Gautam VK. Neonatal separation of distal humeral epiphysis during Caesarean section: A case report. Journal of Orthopaedic Surgery (Hong Kong). 2011; 19 (3):376-378. DOI: 10.1177/230949901101900325 - 64.
Ratti C, Guindani N, Riva G, Callegari L, Grassi FA, Murena L. Transphyseal elbow fracture in newborn: Review of literature. Musculoskeletal Surgery. 2015; 99 (Suppl. 1):S99-S105. DOI: 10.1007/s12306-015-0366-z - 65.
Kay M, Simpkins C, Shipman P, Whitewood C. Diagnosing neonatal transphyseal fractures of the distal humerus. Journal of Medical Imaging and Radiation Oncology. 2017; 61 (4):494-499. DOI: 10.1111/1754-9485.12607 - 66.
Laliotis N. Bone lesions in children with neurofibromatosis. In: Book Neurofibromatosis. London, UK: Intechopen; 2021. DOI: 10.5772/intechopen.97802 - 67.
Koo WW, Sherman R, Succop P, Oestreich AE, Tsang RC, Krug-Wispe SK, et al. Sequential bone mineral content in small preterm infants with and without fractures and rickets. Journal of Bone and Mineral Research. 1988; 3 (2):193-197. DOI: 10.1002/jbmr.5650030211 - 68.
Angelis S, Vynichakis G, Trellopoulos A, Mirtsios H, Michelarakis JΝ. Trangling congenital constriction ring band of the forearm with fracture: A rare case report. Cureus. 2019; 11 (3):e4189. DOI: 10.7759/cureus.4189 - 69.
Nistala H, Mäkitie O, Jüppner H. Caffey disease: New perspectives on old questions. Bone. 2014; 60 :264-251. DOI: 10.1016/j.bone.2013.12.030 - 70.
Elfatairy KK, Ehrlich L, Porrino J, Wang A. Congenital pseudarthrosis of the forearm as a single manifestation of neurofibromatosis type 1 at birth: A case report. Clinical Imaging. 2021; 78 :214-216. DOI: 10.1016/j.clinimag.2021.04.032 - 71.
Lee GS, Methratta ST, Frasier LD. Classic metaphyseal lesion of distal tibia following footling breech delivery. Pediatric Radiology. 2019; 49 (13):1840-1842. DOI: 10.1007/s00247-019-04490-6 - 72.
Lysack JT, Soboleski D. Classic metaphyseal lesion following external cephalic version and cesarean section. Pediatric Radiology. 2003; 33 (6):422-424. DOI: 10.1007/s00247-003-0914-9 - 73.
Kaplan M, Dollberg M, Wajntraub G, Itzchaki M. Fractured long bones in a term infant delivered by cesarian section. Pediatric Radiology. 1987; 17 (3):256-257. DOI: 10.1007/BF02388179 - 74.
Vialle R, Piétin-Vialle C, Ilharreborde B, Dauger S, Vinchon M, Glorion C. Spinal cord injuries at birth: A multicenter review of nine cases. Maternal Fetal and Neonatal Medicine. 2007; 20 (6):435-440. DOI: 10.1080/14767050701288325 - 75.
Caird MS, Reddy S, Ganley TJ, Drummond DS. Cervical spine fracture-dislocation birth injury: Prevention, recognition, and implications for the orthopaedic surgeon. Journal of Pediatric Orthopedics. 2005; 25 (4):484-486. DOI: 10.1097/01.bpo.0000158006.61294.ff - 76.
Menticoglou SM, Perlman M, Manning FA. High cervical spinal cord injury in neonates delivered with forceps: Report of 15 cases. Obstetrics and Gynecology. 1995; 86 (4 Pt 1):589-594. DOI: 10.1016/0029-7844(95)00213-b - 77.
Lee CC, Chou IJ, Chang YJ, Chiang MC. Unusual presentations of birth related cervical spinal cord injury. Frontiers in Pediatrics. 2020; 8 :514. DOI: 10.3389/fped.2020.00514