A 5-hour-old girl is evaluated in the newborn nursery due to "crying a lot." She was born at 40 weeks gestation by vacuum-assisted vaginal delivery to a mother with gestational diabetes mellitus. The delivery was complicated by a prolonged second stage of labor due to difficulty in delivering the shoulders. Estimated fetal weight on prenatal ultrasound was 4 kg (8.8 lb). The patient's birth weight was 4.6 kg (10 lb). Physical examination shows a small area of scalp edema that does not cross suture lines. Palpation of the left clavicular bone reveals crepitus. Passive movement of the left upper extremity elicits crying. Moro reflex is decreased on the left. Bilateral extremities are neurovascularly intact. Which of the following is the best next step in management of this patient?

Question

A 5-hour-old girl is evaluated in the newborn nursery due to "crying a lot."  She was born at 40 weeks gestation by vacuum-assisted vaginal delivery to a mother with gestational diabetes mellitus.  The delivery was complicated by a prolonged second stage of labor due to difficulty in delivering the shoulders.  Estimated fetal weight on prenatal ultrasound was 4 kg (8.8 lb).  The patient's birth weight was 4.6 kg (10 lb).  Physical examination shows a small area of scalp edema that does not cross suture lines.  Palpation of the left clavicular bone reveals crepitus.  Passive movement of the left upper extremity elicits crying.  Moro reflex is decreased on the left.  Bilateral extremities are neurovascularly intact.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d708_d5b3_bc81_7d4728064e19_MD0003_00 This newborn with crepitus over the clavicle, asymmetric Moro reflex, and pain with passive motion of the upper extremity has a displaced clavicular fracture. Neonatal clavicular fractures are typically due to a difficult delivery. Risk factors include birth weight >4 kg (often associated with maternal gestational diabetes mellitus), shoulder dystocia, and vacuum delivery. Vacuum extraction can also cause a subperiosteal bleed (ie, cephalohematoma), as seen in this patient. cephalohematoma X-rays are performed to confirm the fracture. Because neonatal clavicular fractures usually heal rapidly (7-10 days) with no long-term sequelae, management includes parental reassurance and guidance on gentle handling. To decrease pain, arm motion may be restricted by pinning the infant's sleeve to the shirt. fracture (Choice A) Analgesics (eg, acetaminophen) can be given to decrease pain. However, aspirin is generally avoided in infants and children due to the risk of Reye syndrome. (Choice B) Closed reduction is appropriate treatment for shoulder dislocation, which rarely occurs in neonates and would not cause clavicular crepitus. (Choices C and D) Traumatic clavicular fractures in older children are less likely to heal spontaneously and may require treatment. Displaced fractures are often surgically reduced, and nondisplaced fractures are typically managed with a figure-of-8 splint. Educational objective: Birth weight >4 kg, shoulder dystocia, and vacuum delivery are risk factors for neonatal clavicular fractures. Management includes reassurance and gentle handling, as most neonatal clavicular fractures heal rapidly without complications. References: Neonatal clavicular fracture: recent 10 year study. (http://www.ncbi.nlm.nih.gov/pubmed/25203556) Birth fracture of the clavicle. (http://www.ncbi.nlm.nih.gov/pubmed/22123402)

A 5-Hour-Old Girl Is Evaluated in the Newborn Nursery Due