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CLINICAL ARTICLE
Birth-associated long-bone fractures
Asma Basha a
, Zouhair Amarin b,
⁎, Freih Abu-Hassan c
a
Department of Obstetrics and Gynecology, University of Jordan, Amman, Jordan
b
Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan
c
Department of Special Surgery, Orthopedic and Trauma Surgery Section, University of Jordan, Amman, Jordan
a b s t r a c t
a r t i c l e i n f o
Article history:
Received 16 March 2013
Received in revised form 13 May 2013
Accepted 23 July 2013
Keywords:
Cesarean delivery
Femur fracture
Humerus fracture
Objective: To assess the incidence and outcome of neonatal long-bone fractures at a tertiary teaching hospital.
Methods: A retrospective study of all neonates with long-bone fractures delivered at Jordan University Hospital
between January 1, 2000, and December 31, 2010. Results: Among a total of 34 519 live births, 8 neonates had
a long-bone fracture (incidence 0.23/1000 live births); of these, 6 had a femur fracture (0.17/1000 live births)
and 2 had a humerus fracture (0.05/1000 live births). The route of delivery was emergency cesarean delivery
for 6 infants, elective cesarean delivery for 1 infant, and the vaginal route for 1 infant. The mean birth weight
was 2723 g. All neonates weighed more than 2200 g and their gestational age was more than 35 weeks, with
the exception of 1 neonate born at 31 weeks weighing 1500 g. The mean time interval from birth to fracture
diagnosis was 1.5 days. All fractures healed with no residual deformity. Conclusion: Emergency cesarean delivery
carries a higher risk of long-bone fracture than vaginal delivery. Prematurity, malpresentation, abnormal lie, and
multiple pregnancies may predispose to long-bone fractures. The prognosis of birth-associated long-bone frac-
tures is good.
© 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Birth injuries are uncommon, occurring in less than 1% of live births
[1]. Neonates who are diagnosed with a fracture in the first week of life,
in the absence of known postnatal trauma, are considered to have a
birth fracture [2]. It is known that difficult birth requiring consider-
able traction can result in neonatal fractures [3]. Although cesarean
delivery can reduce these fractures [4], femur and humerus fractures
still occur [2,5–8].
The aim of the present study was to assess the incidence, risk factors,
modalities of treatment, and outcomes of birth-associated femur and
humerus neonatal fractures during an 11-year period at a tertiary aca-
demic hospital.
2. Materials and methods
The present study was a retrospective study of all neonates who
had a long-bone fracture obtained during delivery at Jordan Uni-
versity Hospital in Amman, Jordan, between January 1, 2000, and
December 31, 2010.
Data were obtained from the medical files and included maternal
age, gravidity, parity, obstetric history, gestational age, fetal lie and pre-
sentation, number of fetuses in the pregnancy, mode of delivery, type of
analgesia, fetal gender, neonatal weight, Apgar score at 1 and 5 minutes,
medical level of the attending physician, type of fracture, treatment, and
outcome. To ensure that no cases were overlooked, the discharge notes
of all neonates were reviewed. A cross-check was made with the
discharge notes of all neonates treated at the orthopedic department
during the study period.
The study included all live births irrespective of gestational age, and
all stillbirths after 24 weeks of pregnancy. Infants with fractures that
were acquired after delivery, irrespective of the cause, were not included
in the study.
During the study period, the residency program involved 4 years
training. Briefly, first-year residents spend the first 6 months as ob-
servers before conducting vaginal deliveries. In the second year, they as-
sist at assisted vaginal deliveries and act as assistants at cesarean
deliveries. In the third year, they perform elective uncomplicated cesar-
ean deliveries. During the fourth year, residents are able to perform
complex deliveries, including more complex elective and emergency
cesarean deliveries.
The hospital’s Institutional Review Board approved the study as
being exempt from requiring consent. Simple descriptive analyses for
frequency distributions were conducted.
3. Results
During the study period, there were 34 519 live births, with 8 neo-
nates having long-bone fractures (0.23/1000 live births); 6 were
femur fractures (0.17/1000 live births) and 2 were humerus fractures
(0.05/1000 live births) (Table 1). The mean birth weight of the infants
International Journal of Gynecology and Obstetrics 123 (2013) 127–130
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Jordan University
of Science and Technology, PO Box 630017, Irbid 22110, Jordan. Tel.: +962 797424 900;
fax: +962 27201064.
E-mail address: zoamarin@hotmail.com (Z. Amarin).
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijgo.2013.05.013
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics
journal homepage: www.elsevier.com/locate/ijgo

3. Author's personal copy
with long-bone fractures was 2723 g (range 1500–3600 g). All 8 new-
borns weighed 2200 g or more and were born after at least 35 weeks
of pregnancy, with the exception of 1 infant who was born at
31 weeks weighing 1500 g. Six of the neonates were male and 2 were
female. Apgar scores ranged between 6 and 8 at 1 minute and between
8 and 9 at 5 minutes, with the exception of 1 infant with an Apgar score
of 4 at 1 minute and of 7 at 5 minutes (case 7 in Table 1).
The majority (7 [87.5%] of the long-bone fractures were associated
with cesarean delivery (6 [75.0%] emergency and 1 [12.5%] elective);
only 1 (12.5%) fracture was associated with vaginal delivery (Table 1).
Of the 7 cesarean deliveries, 6 (85.7%) were performed under general
anesthesia and 1 (14.3%) under spinal analgesia.
The mean duration from delivery to fracture diagnosis was 1.5 days
(range 1–3 days) (Table 1). In 6 infants, the fractures were noticed im-
mediately after birth or on the day of injury. Two fractures were noticed
on the second and third day of delivery, respectively. All infants had ex-
cessive crying upon holding. In infants with a femur fracture, the thigh
was swollen and held motionless; in infants with a humerus fracture,
the arm was swollen and held in a pseudo-paralytic position.
Of the 6 infants with a femur fracture, 5 (83.3%; cases 1–4 and 6 in
Table 1) were born by emergency cesarean delivery. The first case was
a term pregnancy in labor with cephalic presentation and malposition.
Emergency cesarean delivery under spinal analgesia was performed
for failure to progress. The operator was a fourth-year resident. The
fetus was delivered by breech extraction. Mother and infant were
discharged home on the third day. The infant had a swollen left thigh
with excessive crying upon holding, for which it was readmitted and
diagnosed to have a left transverse femur shaft fracture. This was
managed with a Pavlik harness. After 2 weeks, good callus formation
was seen on X-ray, with full range of movement. The infant was lost
to follow-up.
The second case was a term pregnancy with the fetus in transverse
lie. The mother was admitted in labor. Emergency cesarean delivery
was performed under general anesthesia and the fetus was delivered
by breech extraction by a fourth-year resident. On the same day, the
neonate was noticed to have a swollen right thigh and was diagnosed
with transverse subtrochanteric fracture of the right femur. This
was managed with a splint with good callus formation on X-ray. After
6 months, the infant had full range of movement with no deformity.
The third case was the child of an unscheduled woman in labor with
the fetus in breech presentation post-term. Emergency cesarean deliv-
ery was performed under general anesthesia by a fourth-year resident.
There was thick meconium and the newborn required resuscitation,
after which it was suspected to have a right femur fracture. A mid-
shaft spiral fracture of the right femur, a transverse non-displaced
right tibial shaft fracture, and an old left femur fracture were diagnosed.
The newborn was managed by splintage using 2 tongue depressors. A
diagnosis of osteogenesis imperfecta was made. At follow-up
2 weeks later, good healing was confirmed. Multiple fractures fol-
lowed during childhood.
The fourth case was the child of a woman in labor at 36 weeks of
pregnancy, with oblique lie. This mother had late booking with only 1
prenatal care visit. Emergency cesarean delivery was performed under
general anesthesia by her specialist. The fetal head was delivered first.
This newborn was dysmorphic with scoliosis, club feet, bilateral tibial
varum, and an obvious angulation of the right femur. A mid-shaft
femur fracture was diagnosed and treated by splintage. After 2 days, a
mid-shaft fracture of the left femur was discovered and treated. A diag-
nosis of congenital neuromuscular disorder was made. Follow-up was
complicated with multiple other orthopedic operations.
The fifth fracture occurred at an elective cesarean delivery for a twin
pregnancy, with the first twin in transverse lie. The cesarean delivery
was performed under general anesthesia by a fourth-year resident.
Soon after delivery, the first twin was discovered to have a swollen
right thigh. A mid-shaft spiral fracture of the femur was seen on X-ray.
Bilateral skin traction resulted in poor alignment; therefore, gallows
traction was applied. After 3 weeks, there was good callus formation
with good alignment and full range of movement. The infant was lost
to follow-up.
The sixth fracture was seen in the child of a woman with a triplet
pregnancy at 30 weeks, with placental abruption and breech presenta-
tion of the first fetus. Emergency cesarean delivery with breech extrac-
tion was performed under general anesthesia by a fourth-year resident.
On the next day, the newborn had a swollen right thigh and was diag-
nosed with a spiral fracture of the proximal end of his femur. Splintage
with 2 tongue depressors was implemented, to a very good result, with
full range of movement and no deformity after 6 months of follow-up.
Of the 2 humerus fractures, the first (case 7 in Table 1) occurred after
an uncomplicated vaginal delivery attended by a second-year resident.
On the day of delivery, the neonate was noticed to have left arm swell-
ing with pseudo-paralysis and excessive crying. A mid-shaft fracture of
the left humerus was seen on X-ray. Splintage and sling were applied for
2 weeks. At follow-up, the healing was good, with full range of move-
ment and no neurologic deficit.
The second humerus fracture (case 8 in Table 1) occurred at an
emergency cesarean delivery under general anesthesia for placental
abruption and a non-reassuring fetal cardiotocogram at 35 weeks of
pregnancy. The fetus was in cephalic presentation. The primary operator
Table 1
Obstetric and neonatal outcome characteristics.
Case
no.
Mother’s
age and
parity
Gestational
age, wk
Presentation Sex Birth
weight,
g
Number of
infants per
current
pregnancy
Mode of
delivery
Anesthesia Level of
operator
Affected
bone
Time to
diagnosis
Apgar
score at
1/5 min
Notes
1 23 years, G3P0 37 Cephalic M 2950 1 EmCD
BE
Spinal Fourth year Lt femur 3 days 6/8 RM
2 29 years, G2P1 40 Transverse M 2800 1 EmCD
BE
GA Fourth year Rt femur First day 6/8 IM
3 26 years, G4P3 41 Breech M 3280 1 EmCD
BE
GA Fourth year Rt femur
Rt tibia
At delivery 8/9 OI, IM
4 40 years, G6P3 + 2 36 Oblique M 2750 1 EmCD GA Specialist Bilateral
femur
Rt 1 day,
Lt 2 days
8/9 NM, IM
5 39 years, G6P4 + 1 37 Transverse F 2200 2 ECD GA Fourth year Rt femur Soon after
birth
6/8 IM
6 31 years, G1P0 30 Breech F 1500 3 EmCD
BE
GA Fourth year Rt femur First day 8/9 IM
7 46 years, G9P6 + 2 40 Cephalic M 2700 1 SVD None Second year Lt humerus First day 4/7 RM
8 32 years, G6P5 35 Cephalic M 3600 1 EmCD
BE
GA Fourth year Lt humerus First day 8/9 RM
Abbreviations: BE, breech extraction; ECD, elective cesarean delivery; EmCD, emergency cesarean delivery; F, female; G, gravida; GA, general anesthesia; IM, intact membranes; Lt, left;
M, male; NM, neuromyopathy; OI, osteogenesis imperfecta; P, parity; RM, ruptured membranes; Rt, right; SVD, spontaneous vaginal delivery.
128 A. Basha et al. / International Journal of Gynecology and Obstetrics 123 (2013) 127–130

4. Author's personal copy
was a third-year resident because the fourth-year resident was engaged
with another emergency cesarean delivery. There was a difficulty in
delivering the fetus in the cephalic presentation, so the fourth-year
resident was called from the other theater, who delivered the fetus by
reverse breech extraction, with Løveset’s maneuver to deliver the
arms. The neonate was transferred to the neonatal intensive care unit.
There, its left arm was noticed to be swollen and deformed. A mid-
shaft displaced transverse fracture of the left humerus was diagnosed.
Splintage using 2 tongue depressors with an arm sling was applied.
After 2 weeks, there was good healing. After 1 month, the range of
movement was full without any obvious deformity or neurologic deficit.
4. Discussion
Forced obstetric maneuvers always carry a risk of soft-tissue injury,
long-bone fracture, and related neonatal complications [5]. Risk factors
include large and very small fetuses, breech presentation, external
version, difficult delivery, inadequate uterine relaxation, small uterine
incision, twin pregnancies, prematurity, osteogenesis imperfecta, and
osteoporosis [9]. Historically, long-bone fractures have been attributed
to breech maneuvers at vaginal delivery, but because cesarean de-
liveries are becoming more popular and include breech maneuvers,
the incidence of long-bone fractures may be on the increase. Large
population-based and case-control studies [10–14] have shown a signif-
icant reduction in perinatal and infant mortality if term breech pregnan-
cies are delivered by planned cesarean delivery. Those reports have led
to an increased incidence of cesarean delivery for malpresentation be-
cause vaginal breech deliveries are being avoided. However, in breech
presentation, abdominal and vaginal delivery maneuvers are similar. A
previous report [15] documented a decreased, but not eliminated, risk
of femur fracture when the infant is delivered by cesarean delivery.
Such fracture injuries are caused by forced, sudden traction with twist-
ing and pulling maneuvers, small uterine incision, or inadequate uterine
relaxation [9,15–18].
The findings of the present study are in agreement with other
reports [5,9,16,19], which showed that long-bone fractures were more
frequently associated with cesarean breech deliveries compared with
vaginal deliveries. Of the 6 neonates with femur fractures who were
delivered by cesarean, 2 were breech presentation (cases 3 and 6) and
another 3 had malpresentation or malposition (cases 1, 2, and 5), of
which 4 were delivered by breech extraction. One of the humerus frac-
tures (case 8) occurred in a preterm cephalic fetus who was delivered
by breech extraction at cesarean delivery, and the second humerus frac-
ture (case 7) followed normal vaginal delivery.
The incidence of birth-related femur fracture in the present study
was 0.17/1000 live births. This is in agreement with other studies
[1,20,21], in which the incidence of femur fractures at birth varied
between 0.12 and 0.18 per 1000 live births.
In the present study, 6 of the 7 cesarean deliveries that were associ-
ated with long-bone fractures were performed by fourth-year obstetric
residents, and only 1 by a specialist. Although the numbers are small, it
may be hypothesized that with increased seniority there would be a
decrease in the incidence of such fractures. In addition, most of the inju-
ries occurred under general anesthesia, which correlates with an inap-
propriate application of force during delivery [1,7]. This may signify
the importance of good training and supervision of residents for the
implementation of safer delivery techniques.
Morris et al. [1] found that the time span from delivery to diagnosis
of femur fractures averaged 6.3 days. Soft-tissue swelling, joint stiffness,
and focal tenderness and irritability often appear later, and may explain
the delay in diagnosis [19]. In the present study, the time from delivery
to diagnosis averaged 1.5 days. However, 66.6% (4/6) had no evidence
of femur injury on immediate postnatal examination, which compares
with the study of Morris et al. [1], where 85.7% (6/7) of cases were not
suspected on immediate postnatal examination.
The prognosis of diaphyseal fractures of the femur is good. The
recommended modalities of treatment for femur fractures in neonates
include spica cast, Pavlik harness, gallows traction, and Bryant traction
[1,20,22]. In the present case series, a variety of treatment regimens
were used including splintage, gallows traction, spica casting, and Pavlik
harness. All gave good clinical and radiologic results within 1 month
of injury.
The incidence of birth-related humerus fracture in the present study
was 0.06/1000 live births. This is in agreement with other studies, in
which humerus fractures at birth varied between 0.1 and 0.2 fractures
per 1000 live births [22]. Neurovascular injuries resulting from humerus
diaphyseal fractures are rare in neonates [23]. Minimal intervention
with soft immobilization is usually sufficient for their treatment [19].
In the present study, the infants with humerus fractures were treated
with splintage and sling, with good healing and full range of movement
without obvious deformity or any neurologic deficit.
In the present study, 2 (25%) cases had fetal osteoporosis, which may
have resulted from osteogenesis imperfecta (case 3) and congenital
neuromuscular disorder (case 4). Osteogenesis imperfecta is one of
the most common skeletal disorders characterized by abnormal growth
and development of bone and cartilage. Accurate prenatal sonographic
diagnosis is possible. Ultrasound screening of all pregnant women in
the second trimester is an efficient method for the detection of many
such malformations [24].
One of the limitations of the present study is the possibility that
some cases could have been missed because 3 of the femur fractures
were diagnosed a few days after delivery. Furthermore, having been
discharged home, some cases might have been seen at other hospitals.
In conclusion, clinicians must be aware that abdominal delivery does
not preclude the occurrence of femur and humerus fractures. Emergen-
cy cesarean delivery carries an increased risk for long-bone fracture
mostly in premature fetuses, fetuses with malpresentation, and multi-
ple pregnancies, with the need for good training in safer delivery tech-
niques. Although these fractures heal well, the possibility of pathologic
fractures has to be kept in mind. A higher index of suspicion would
help in early detection and treatment.
Conflict of interest
The authors have no conflicts of interest.
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