We discuss the diagnosis and management of clavicle fractures and brachial plexus palsy. We are joined by Chris Stutz, MD, Assistant Professor of Pediatric Orthopedic and Hand Surgery at the Texas Scottish Rite Hospital for Children in Dallas and UT Southwestern.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In today's episode, we'll be discussing clavicle fractures and brachial plexus palsy. We are recording remotely, due to the ongoing COVID pandemic. We are joined today by Dr. Chris Stutz, Assistant Professor of Pediatric Orthopedic and Hand Surgery at the Texas Scottish Rite Hospital for Children in Dallas and UT Southwestern.
Dr. Chris Stutz:
This is Chris.
Dr. Neeta Goli:
Hi, Dr. Stutz, thanks for joining us today.
Dr. Chris Stutz:
Hi, thanks for having me.
Dr. Neeta Goli:
The most common fracture that we see in the newborn nursery is a clavicle fracture. These typically have an excellent prognosis with conservative management, but can be concerning to parents and caregivers. In today's episode, we'll learn about their presentation, evaluation, management, and prognosis. To start off with, Dr Stutz, please, can you tell us how common it is for an infant to develop a clavicle fracture and/or a brachial plexus palsy?
Dr. Chris Stutz:
Well, the studies differ in the occurrence of clavicle fractures necessarily. There's probably better information regarding brachial plexus injuries, which has held steady at 1 to 1-1/2% per thousand. Some studies will say even less.
Dr. Neeta Goli:
What are some risk factors for an infant to develop a clavicle fracture?
Dr. Chris Stutz:
Well, from a standpoint of risk factors, probably the most well-known is birth weight; from our standpoint, at least in the orthopedic literature. I think defining the risk factors may be better explained in the obstetric literature. Clearly, there may be some risk factors associated with pelvic anatomy and the mother and those things, which are less in my specialty and more in the obstetric specialty. The orthopedic literature really highlights a traumatic or difficult birth and shoulder dystocia, as well as sort of heavy babies as being the most associated with clavicle fractures at birth.
Dr. Neeta Goli:
Okay. When we're examining our newborns, what physical exam findings might be suggestive of a clavicle fracture?
Dr. Chris Stutz:
Most clavicle fractures happen in compression, and not necessarily distraction per se. A lot of times there's a prominence over the mid-shaft of the clavicle; a bump or a bruise, even, as a hematoma develops around the fracture. The clavicle is a subcutaneous bone. So a hematoma is very quickly evident after fracture. That may be the first time that you see it. You may palpate some crepitus or a prominence, most often in the middle of the clavicle bone. Then at the same time, it's uncomfortable to the infant. An otherwise resting, comfortable infant may show signs of distress or crying if you palpate that region, because it's painful.
Dr. Neeta Goli:
Then do you have any tips for performing the exam in the most sensitive manner, or most accurately?
Dr. Chris Stutz:
I don't think there's any real tips from my standpoint. I think probably the most definitive way to diagnose it is to palpate it. Certainly an x-ray, or even ultrasound, can be somewhat diagnostic, depending on the availability and expertise in the modality. But from a physical exam standpoint, I think the most reliable way is to put your fingers on it and detect the discontinuity, or prominence, if you will; of the displaced clavicle fracture.
Dr. Neeta Goli:
From your standpoint, is imaging ever necessary to make the diagnosis?
Dr. Chris Stutz:
Rarely so. For me, I think as an orthopedist, this is a fracture that heals 100% of the time. So imaging in a newborn infant is not something that I generally follow up on. As an example, when referred to me most often, these are confirmed with imaging in the neonatal intensive care unit. Which I don't think is wrong, but in follow-up for me, I rarely get an x-ray because they so reliably heal and remodel. So the displacement and such is not of much clinical concern to me in a newborn, because of the remodeling potential. For diagnostic purposes, if unsure or there's some discrepancy as to whether it's present or not: I don't think an image; again, an x-ray versus an ultrasound, based on capabilities and availability; I think, to confirm the diagnosis, is completely within standard of care.
Dr. Neeta Goli:
Okay. Then you mentioned this briefly, but if you do have a baby who has physical exam findings consistent with an isolated clavicle fracture; no concern for brachial plexus palsy; what do you recommend as their management? And what would the typical outcome be for those babies?
Dr. Chris Stutz:
The clavicle fracture with the brachial plexus palsy is oftentimes concomitant diagnoses; but treated the same, even in isolation. A clavicle fracture with a brachial plexus palsy, I would treat the same as an isolated clavicle fracture and no evidence of a nerve injury. For that, a clavicle fracture is usually best treated with comfort measures. Swaddling the infant, holding the arm adducted to the side. And within a onesie or some sort of swaddling, to limit the movement until the clavicle fracture becomes stable. That usually happens in a week to 10 days in an infant of that age. A newborn, that is.
Dr. Chris Stutz:
The brachial plexus palsy is very different. Immediately, a brachial plexus palsy with a clavicle fracture is treated with observation. Most brachial plexus palsies, if not all brachial plexus palsies, are treated with observation for spontaneous recovery in the immediate sense. But with a clavicle fracture, it's always treated observation. Without a clavicle fracture, I will oftentimes institute early therapy for range of motion with the neonatal intensive care therapists, for glenohumeral and elbow motion. With a clavicle fracture, we usually hold off for a few weeks; just to allow the clavicle fracture to heal and not to induce any discomfort to the infant.
Dr. Neeta Goli:
Can you speak to the way that the bone heals in terms of callus formation and prognosis?
Dr. Chris Stutz:
One of the benefits of kids' bones is that they heal robustly, because they're covered with a thick periosteum. Oftentimes, even in older kids, we get away without surgical fixation of fractures that you may have seen in adult patients, because of this thick layer of periosteum. Now, the healing is somewhat different. When bones are stabilized with plates and screws, they heal directly: where bone heals from Point A to Point B. When they're not fixed, like we treat infant clavicle fractures and other kids' fractures, they heal with a callus. Which is a large, almost golf ball–like volume of bone that surrounds the two broken ends, and will slowly remodel.
Dr. Chris Stutz:
When this callus forms, which in a newborn infant will happen very quickly; between two weeks and three weeks; that signifies healing of the bone. At that time point, most of these, if not all of these fractures are stable, and therefore non-painful. Over a period of time; again, much more accelerated in the newborn period; that callus will remodel in kids such that that ball of bone will slowly disappear as the body reconstructs the cortical structure of the bone that's broken.
Dr. Chris Stutz:
In a clavicle, although you may be able to feel the bump beneath the subcutaneous tissue for even several months in a newborn; usually by about three or four months of age, that callus is completely remodeled. Such that it's difficult to tell the difference when palpating both clavicles.
Dr. Neeta Goli:
What signs on physical exam would be indicative to us that a baby has a brachial plexus palsy?
Dr. Chris Stutz:
Right. The most common form of brachial plexus palsy in infants is what goes by the eponym of an Erb's palsy, which is an upper trunk palsy; a C5 and C6 involvement. C5 and C6 control, grossly, your elbow and shoulder motion. Infants with C5 and C6 dysfunction have a hard time elevating the shoulder. And in the lying position, have a hard time bending the elbow. You oftentimes see them in an internally rotated shoulder-elbow extended position.
Dr. Chris Stutz:
Those that have more lower trunk involvement will have a very flail hand. One that just rests in a limp position. Whereas those that have less affliction to the lower nerve roots take that waiter's tip–type position, where the wrist is in flexion and the fingers may be flexed, because the lower roots of the plexus are uninjured.
Dr. Chris Stutz:
More uncommonly is a pan-plexus palsy, where the entire brachial plexus can be injured; not just the upper trunks. If the entirety of the brachial plexus is injured, occasionally the sympathetic chain, which anatomically runs very near to the lower plexus roots, can also be injured.
Dr. Chris Stutz:
Not only will there be a flail upper limb with very little to no movement from shoulder to fingertips, but you can also see what's called a Horner's sign, where the eyelid droops and the eye is often dry from the sympathetic chain injury. This is a very definitive marker of a more severe type plexus injury. And one that may tend more towards surgical intervention from a neurologic standpoint than some of the higher injuries, which can be more transient in nature.
Dr. Neeta Goli:
If we do suspect that an infant has a brachial plexus palsy, what should our next steps be?
Dr. Chris Stutz:
I think the most important thing from the start is recognition. And with recognition comes referral, because there is a time association with regards to treatment. There is a point in which the nerve injury can become old enough that nerve surgery is not likely to be helpful.
Dr. Chris Stutz:
If I was to place an emphasis on things, recognition is of the utmost importance. Once it's recognized, then appropriate referral to the center. Either close to home; here in Dallas, certainly Scottish Rite. We have an ample brachial plexus clinic here with therapists and myself and others in a multidisciplinary team.
Dr. Chris Stutz:
Then immediately, in the NICU, again, with the clavicle fracture, I would do little more than swath the child for comfort until the clavicle fracture heals.
Dr. Chris Stutz:
Without a clavicle fracture, especially for those kids who may be spending a prolonged time with you; several months, especially; the implementation of some early therapy maneuvers for glenohumeral motion, as well as elbow motion is more than appropriate.
Dr. Chris Stutz:
As an outpatient; for those who don't spend a long time with you; I usually like to see the kids somewhere between two and three months of age. So that I have ample time to talk to the family regarding treatment recommendations and treatment options based on the severity of the injury. As well as enough time, if surgery is necessary, to complete that before the clock runs out on nerve healing.
Dr. Neeta Goli:
You mentioned the clock running out. What is your typical timeframe for being worried about that?
Dr. Chris Stutz:
Sure. Typical treatment; what remains the gold standard today in treatment is nerve grafting with sural nerve graft, and excision of nerve injuries for those patients that don't recover adequately. A common question I get is, "What is adequate recovery?" Although arguable, most of us will hover around anti-gravity strength in elbow flexion by about six months of age. For those kids who don't recover significantly neurologically prior to that time point; at about six months of age, the decision for a brachial plexus exploration with nerve grafting is usually made.
Dr. Chris Stutz:
Now, that gets complicated because nerve transfer techniques, where we move a nerve from one muscle to another, has extended that timeframe for us in some kids. There are some kids who you may see getting nerve surgery eight, nine, 10, and even greater: 12, 13, 14 months for isolated deficits that are persistent after a brachial plexus injury.
Dr. Neeta Goli:
Then you briefly mentioned this; or we've gone over this a little bit. But what are the expected long-term outcomes for infants with brachial plexus palsies?
Dr. Chris Stutz:
Sure. For the vast majority, the outcomes are great. If a hundred kids present with a brachial plexus palsy, nerve surgery may not be required in more than 10 or 15 of those kids. So the outcomes with regards to the need for surgery are quite good.
Dr. Chris Stutz:
Now, that doesn't necessarily mean that there won't be asymmetric function, or the need for some sort of musculoskeletal intervention down the road. Most often, the interventions include realigning the shoulder to promote formation of the glenohumeral joint such that it's a congruent joint that moves well, despite the fact that some of the shoulder girdle muscles may be persistently weak after that injury.
Dr. Chris Stutz:
So in general, I would say the vast majority of brachial plexus injuries have good outcomes. Although they may have some asymmetric movement of their upper extremities or shoulders. I generally tell parents that asymmetry doesn't necessarily equal a deficit. Just because one shoulder moves differently to place the hand in space doesn't mean that it doesn't function equal to the other side. It just may look different in the way the shoulder blade moves.
Dr. Chris Stutz:
So the outcomes in general are good. The rates of surgery for nerve surgery may be between 10 and 15% of all comers. The rates of musculoskeletal surgery may be closer to 30% of all comers, based on the type of injury and practice. Everybody's practice is somewhat different as well.
Dr. Neeta Goli:
So functionally for these kids, when they get older, like you mentioned, some might need the surgery. But typically, you wouldn't necessarily expect any restriction in terms of activity? Or restrictions athletics, and things like that?
Dr. Chris Stutz:
It's very rare that I place restrictions on kids with brachial plexus palsies. Those with the most severe limbs, where the entire plexus has been avulsed, may have difficulty in participation with some activities. That's not the common place. I think those kids, thankfully, are few with regards to the majority of presentations.
Dr. Chris Stutz:
Most kids may have some asymmetry. They may have some weakness, and they may require activity modifications or changes in the way they approach common activities. But their ability to participate is usually unrestricted.
Dr. Neeta Goli:
Well, Dr. Stutz, to end the episode today, do you have any advice for our listeners while they care for newborns?
Dr. Chris Stutz:
I think I would go back to recognition. I think a high index of suspicion for both a clavicle fracture; and if a clavicle fracture seen for the possibility that there's an underlying brachial plexus injury; is something that I would emphasize. Because although there's many things that I take care of that may not have a timestamp on them, nerve injury is one of those things that if recognized late, it can change the course of available treatment options. So early recognition and referral, I think, is of utmost importance.
Dr. Chris Stutz:
Lastly, I'd add that for parents who are in the NICU and have lots of things to worry about; clavicles always heal. Although it may be uncomfortable; may be visual to the parents, and certainly concerning to them; it's very rare that I see a true complication from the actual bony injury of a clavicle fracture.
Dr. Neeta Goli:
Thanks for joining us today, Dr. Stutz.
Dr. Chris Stutz:
Absolutely. Thanks for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational, and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests, and do not necessarily reflect the views of the university.