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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Tsan Yuk Hospital, Hong Kong SAR, Republic of China.
Address reprint requests to: Man-Ho Lam, MBBS, MRCOG, Department of Obstetrics and Gynecology, Princess Margaret Hospital, Lai King Hill Road, Lai Chi Kwok, Kowloon, Hong Kong SAR, Republic of China; E-mail: f1592821{at}netvigator.com.
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ABSTRACT |
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METHODS: A retrospective case-control study was performed onalltheinfantsdiagnosedwithclavicularfracturesandborn vaginally between July 1997 and June 2000. For each index case, a control matched for gestational age (within l week), birth weight (within 100 g), and delivered within the same 24-hour period (8 AM to 8 AM), was selected at random from the delivery suite registry. If a control could not be identified within the period, the search was extended to the previous or the following 24-hour period, and the birth weight criterion relaxed to within 250 g. The overall neonatal outcome was compared between the two groups and the morbidity was further analyzed according to whether the infants were large for gestational age (LGA) or not.
RESULTS: Clavicular fracture, found in 1.6% (151 of 9540) of vaginal births, was associated with increased incidence of instrumental delivery (P = .001) and shoulder dystocia (P = .013). The associated morbidity were Erb palsy (P = .007), which was more often found in the LGA infants (P = .055), and cephalhematoma (P = .031), which was only found in the non-LGA infants (odds ratio 4.48, 95% confidence interval 1.23, 16.30). On multivariable analysis, clavicular fracture was excluded as a significant factor in these outcomes after adjusting for the effect of instrumental delivery and shoulder dystocia.
CONCLUSION: Neonatal clavicular fracture is of little clinical significance, and it does not reflect quality of care.
Clavicular fracture in the newborn is considered to be one form of birth trauma, and it has been designated a reportable event in places such as the State of New York.1 Nevertheless, its clinical significance remains disputed. It is reported that most of the infants with clavicular fracture have no long-term morbidity.2 However, clavicular fracture can be associated with other forms of birth trauma, notably brachial plexus injury, and the incidence of Erb palsy in the published reports varied from 0.44%,3 1.7%,2 4%,4 to 5.2%.5 In addition, clavicular fracture is sometimes associated with or attributed to difficulty in the delivery of the fetal trunk, such as in the case of shoulder dystocia,2,3,5,6 and this may in turn be associated with other morbidity such as birth asphyxia. Therefore, it is understandable that clavicular fracture has been proposed as an indicator of quality control.1
In a previous audit in our hospital, two out of 20 (10%) consecutive newborns diagnosed with clavicular fracture were found to have associated Erb palsy, even though no difficulty in delivery was noted in 70% (14 of 20) of these newborns.7 However, it was not stated in the audit whether the two newborns with Erb palsy belonged to those with difficulty in delivery or not. This prompted us to perform a retrospective case control study to examine the risk factors for, and the neonatal morbidity associated with, neonatal clavicular fracture in live-born infants delivered over a 36-month period. The cases and controls were matched for gestational age and birth weight to minimize the confounding effects of gestational age and infant size on the threshold and incidence of obstetric interventions, which could in turn influence neonatal outcome. We also analyzed the data in relation to birth weight percentile ranking, with the neonates categorized into large for gestational age (LGA) and non-LGA subgroups to determine whether infant size would influence the incidence of any associated morbidity.
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MATERIALS AND METHODS |
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In this study, we reviewed all the deliveries in our hospital during the period between July 1997 and June 2000. The identity number of the cases of clavicular fracture were obtained from the monthly perinatal meeting statistics, and the date of delivery was then determined by going through the delivery suite registry. Only the cases delivered vaginally were included in the study. For each index case, a control matched for gestational age (within 1 week), birth weight (to the nearest 100 g), and route of delivery (vaginal delivery) was selected from the other deliveries within the same 24-hour period of the delivery suite roster (8 AM to 8 AM). In this way, both index and control cases were managed by the same obstetric team. Where a suitable control was not available, the search was extended to the 24-hour periods before or after the delivery of the index case, and the birth weight criterion was relaxed to the nearest 250 g. This was done to minimize any possible differences between the management of the involved obstetric staff.
The maternal and neonatal records of the cases and controls were then retrieved for review. Data collected for analysis included the following: gestational age, neonatal measurements, infant sex, Apgar score at 1 and 5 minutes, presence of neonatal morbidity including Erb palsy, cephalhematoma, subarachnoid hemorrhage, treatment for neonatal jaundice, sepsis, meconium aspiration syndrome, and metabolic complications. The presence or absence of instrumental delivery and shoulder dystocia were also compared between the two groups. These factors were analyzed for the overall groups, and then according to the infant size categorized as LGA (birth weight over the 90th percentile according to our local standardized percentile chart) and non-LGA. Statistical analysis was performed with the 
2 or Fisher exact test, depending on the cell size, and the McNemar test, for categoric variables. Multivariable analysis was used to determine the relationship between clavicular fracture and the aforementioned outcomes, with adjustment for the effect of factors including instrumental delivery and shoulder dystocia. The calculation was performed with a commercially available statistical package (Statistical Package for the Social Sciences, 10; SPSS, Chicago, IL). A P value of <.05 was considered significant.
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RESULTS |
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There was no difference between the study and control groups in the maternal age (29.4 ± 4.9 years versus 29.4 ± 5.0 years), pregravid weight (52.4 ± 7.4 kg versus 53.4 ± 7.6 kg), or predelivery weight (66.6 ± 9.0 kg versus 68.2 ± 9.3 kg). However, the study group had reduced maternal height (155.7 ± 5.0 cm versus 157.3 ± 5.5 cm, P = .011).
There was no difference in the mean gestational age (39.7 ± 1.2 weeks versus 39.7 ± 1.1 weeks), birth weight (3447 ± 352 g versus 3423 ± 341 g), crown–heel length (50.5 ± 1.7 cm versus 50.8 ± 1.8 cm), or head circumference (34.2 ± 1.3 cm versus 34.3 ± 1.2 cm), between the study group and controls. However, the incidence of instrumental delivery was significantly higher in the cases (41.4% versus 22.5%, P = .001). On further analysis, this was due to a higher incidence of vacuum extraction (34.4% versus 15.9%, P < .001) but not to forceps delivery (6.6% versus 6.6%) in the study group.
The two groups had similar incidences of male infants, Apgar score <7 at 1 and 5 minutes, cephalhematoma, subarachnoid hemorrhage, treatment for neonatal jaundice, sepsis, meconium aspiration syndrome, and metabolic complications (Table 1
). However, the study group had a significantly higher incidence of shoulder dystocia, Erb palsy, and cephalhematoma. On further analysis, the increased incidence of Erb palsy was related to the higher incidence of shoulder dystocia (odds ratio [OR] 3.68, 95% confidence interval [CI] 1.32, 10.25), whereas that of cephalhematoma was related to the higher incidence of vacuum extraction (OR 2.80, 95% CI 1.60, 4.82).
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2 test P = .896, McNemar test P = .136). Among the LGA infants, Erb palsy was more commonly found in the infants in the study group compared with those in the control group (16.1% versus 0%, 2 test P = .055, McNemar test P = .000, Table 2). Had a larger sample size been reviewed, this difference would have been statistically significant by the 2 test. There was no statistically significant difference in the other aforementioned outcomes.
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2 test P = .000, McNemar test P = .000). However, when analyzed by the 2 test, there was also no difference in the incidence of the aforementioned outcomes except for the incidence of cephalhematoma (OR 4.48, 95% CI 1.23, 16.30, Table 3).
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Of the eight infants with Erb palsy, four had recovered with complete Moro reflex during follow-up assessment between postnatal day 5 to day 17. Of the four remaining infants with incomplete Moro reflex in the postnatal period, one was lost to follow-up, but the other three were traced and confirmed to have full recovery at the time of this study.
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DISCUSSION |
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One other uncommon cause of clavicular fracture is deliberate fracture in the maneuver to overcome shoulder dystocia. The contribution of this factor to the overall incidence of clavicular fracture has not been elaborated in previous reports. In our practice, this is not one of the standard maneuvers, and departmental audit meetings during the period of study had not documented a single case attributed to this cause. This was verified during the study. In a previous audit in our hospital, Erb palsy was found in 10% (2 of 20) of the infants with clavicular fracture, although no difficulties were reported in 70% of the deliveries.7 Although both infants with Erb palsy recovered completely, the findings were by no means reassuring, and it was felt that a reappraisal of the consequences of clavicular fracture in our population is due. Because one of the confounding factors for both forms of trauma is increased fetal size, subgroup analysis was also done in this study according to whether the infants were LGA or non-LGA.
Our results indicate that once birth weight and gestational age were matched, the only neonatal complications associated with clavicular fracture overall were Erb palsy and cephalhematoma, found in 5.3% and 7.9%, respectively, in the study group. However, within the group of LGA infants, no significant difference was found in the incidence of these complications between the study and control groups. This was probably related to the small sample size of LGA infants, because the difference in the incidence of Erb palsy was almost statistically significant (P = .055). For the non-LGA infants, the study group had significantly increased incidence of cephalhematoma only. The seven-fold difference in the incidence of Erb palsy between the LGA and non-LGA infants in the study group suggested that fetal size was the primary underlying factor, and multivariate analysis confirmed that clavicular fracture played no significant role in either Erb palsy or cephalhematoma.
Neonatal clavicular fracture is often clinically silent. A prospective study on 626 consecutive infants delivered vaginally found that although 18 cases of clavicular fracture were identified, only two cases had signs and symptoms on initial examination, whereas another nine were diagnosed on discharge and seven additional cases were identified at the time of the office visit.15 In our previous audit,7 only 40% of the cases were diagnosed before discharge from hospital on day 3. Thus, the majority of the cases of clavicular fracture would have escaped detection unless it was looked for. The long-term prognosis of the fractured clavicle is also excellent, as this heals without clinical sequelae.5 The associated Erb palsy and brachial plexus injury found in previous studies also recovered completely,4,5,7 and this is supported by the findings of this study.
The results of this study suggest that the clinical importance of neonatal clavicular fracture had been overemphasized. The majority of the affected infants did not go through a difficult labor or delivery process.3,10,13,16 Thus, this appears to be an unavoidable event of vaginal birth,16 and it remains questionable whether anyone should be held responsible,3 especially when it is not associated with any significant sequelae or etiologically related complications such as Erb palsy. Therefore, it should not be regarded as an indicator of the quality of obstetric care. Its inclusion as a reportable event serves no useful purpose for the individual or society, other than to increase physician and parental anxiety, and to create the potential risk of unjustified medical litigation. There appears to be no justification in the routine checking and reporting of clavicular fracture, especially in the absence of complications such as Erb palsy.
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Footnotes |
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Received July 24, 2001. Received in revised form November 29, 2001. Accepted December 18, 2001.
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REFERENCES |
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2. Gilbert W, Tchabo J. Fractured clavicle in newborn. Int Surg 1988;73:123–5.[Medline]
3. Peleg D, Hasnin J. Shalev E. Fractured clavicle and Erb’s palsy unrelated to birth trauma. Am J Obstet Gynecol 1997;177:1038–40.[Medline]
4. Kaplan B, Rabinerson D, Avrech OM, Carmi N, Steinberg DM, Merlob P. Fracture of the clavicle in the newborn following normal labor and delivery. Int J Gynaecol Obstet 1998:63:15–20.[Medline]
5. Oppenheim WL, Davis A, Growdon WA, Dorey FJ, Davlin LB. Clavicle fractures in the newborn. Clin Orthop 1990;250:176–80.
6. Brown BL, Lapinski R, Berkowitz GS, Holzman I. Fractured clavicle in the neonate: A retrospective three-year review. Am J Perinat 1994;11:331–3.[Medline]
7. Pun TC, Lee CP, Lao TT. Fractured clavicle and birth trauma. Am J Obstet Gynecol 1998;178:1104–5.
8. Levine MG, Holroyde J, Woods JR, Siddiqi TA, Scot N, Miodovnik M. Birth trauma—incidence and predisposing factors. Obstet Gynecol 1984;63:792–5.
9. Ohel G, Haddad S, Fischer O, Levit A. Clavicular fracture of the neonates: Can it be predicted before birth? Am J Perinat 1993;10:441–3.[Medline]
10. Many A, Brenner SH, Yaron Y, Lusky A, Peyser MR, Lessing JB. Prospective study of incidence and predisposing factors for clavicular fracture in the newborn. Acta Obstet Gynecol Scand 1996;75:378–81.[Medline]
11. Turnpenny PD, Nimmo A. Fractured clavicle of the newborn in a population with a high prevalence of grand multiparity: Analysis of 78 consecutive cases. Br J Obstet Gynaecol 1993;100:338–40.[Medline]
12. Walle T, Sorri AH. Obstetric shoulder injury: Associated risk factors, prediction and prognosis. Acta Obstet Gynecol Scand 1993;72:450–4.[Medline]
13. Perlow JH, Wigton T, Hart J, Strassner HT, Nageotte MP, Wolk BM. Birth trauma. A five-year review of incidence and associated perinatal factors. J Reprod Med 1996;41: 754–60.[Medline]
14. Boyd ME, Usher RH, McLean FH. Fetal macrosomia: Prediction, risks, proposed management. Obstet Gynecol 1983;61:715–22.
15. Joseph PR, Rosenfeld W. Clavicular fractures in neonates. Am J Dis Child 1990;144:165–7.[Abstract]
16. Chez RA, Carlan S, Greenberg SL, Spellacy WN. Fractured clavicle is an unavoidable event. Am J Obstet Gynecol 1994;171:797–8.[Medline]
This article has been cited by other articles:
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  Y.-H. Kuo and M.-H. Lam Reappraisal of Neonatal Clavicular Fracture: Relationship Between Infant Size and Neonatal Mortality Obstet. Gynecol., January 1, 2003; 101(1): 202 - 203. [Full Text] [PDF]
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