Newborn Bone Fractures: Causes, Symptoms & Treatment

What Are Newborn Bone Fractures?

Newborn bone fractures, also called birth fractures or neonatal fractures, are breaks in a baby's bones that occur during the delivery process. The most common type is a clavicle (collarbone) fracture, affecting approximately 0.5-1.6% of all births. Despite being concerning for parents, these injuries typically heal completely within 2-4 weeks.

Birth is a physically demanding process for both mother and baby. As the newborn passes through the birth canal, significant mechanical forces are exerted on the baby's body. While the flexible nature of newborn bones usually allows them to withstand these forces, in some cases the pressure can cause a bone to fracture. This is particularly true during difficult deliveries or when certain risk factors are present.

The occurrence of a birth-related fracture does not necessarily indicate that anything was done incorrectly during delivery. Even with optimal obstetric care, some fractures occur due to the unpredictable nature of childbirth. Healthcare providers must balance the risks to both mother and baby while making delivery decisions, and sometimes fractures happen despite the best care.

Understanding the types, causes, and treatment of newborn fractures can help parents cope with the initial shock of diagnosis and know what to expect during the healing process. The remarkable regenerative capacity of newborn bones means that the vast majority of these injuries heal without any lasting effects.

Types of Birth Fractures

Several bones can be affected during birth, though some are far more common than others. The location and severity of the fracture depend on various factors including the baby's position during delivery, birth weight, and the type of delivery.

• Clavicle (collarbone) fractures: The most common type, accounting for approximately 90% of birth fractures. The clavicle can break when the shoulders have difficulty passing through the birth canal.
• Humerus (upper arm) fractures: The second most common, occurring when the arm is pulled or twisted during delivery, particularly during breech presentations.
• Femur (thigh bone) fractures: Less common but can occur during breech deliveries when traction is applied to the legs.
• Skull fractures: Rare, usually occurring with instrumental deliveries using forceps. Most are linear fractures that heal without intervention.

Medical Classification

From a medical perspective, newborn bone fractures are classified under ICD-10 code P13 (Birth injury to skeleton). This category includes several specific subcodes that healthcare providers use for precise documentation and treatment planning. The classification helps ensure appropriate follow-up care and allows for accurate tracking of these injuries across healthcare systems.

What Causes Bone Fractures During Birth?

Birth fractures occur due to mechanical forces during delivery. Major risk factors include macrosomia (large baby over 4kg), shoulder dystocia (difficulty delivering shoulders), breech presentation, instrumental delivery (forceps or vacuum), and prolonged or difficult labor. Sometimes fractures occur even in uncomplicated deliveries.

The process of childbirth involves significant physical forces as the baby navigates through the birth canal. The pelvis and soft tissues must stretch to accommodate the baby's head and body, and the baby must rotate and flex to fit through this passage. While human anatomy has evolved to make this process possible, certain circumstances can increase the mechanical stress on the baby's bones beyond their capacity to withstand.

Understanding the causes of birth fractures is important for both healthcare providers and parents. For providers, recognizing risk factors allows for better preparation and potentially preventive measures. For parents, understanding why a fracture occurred can help alleviate feelings of guilt or blame, as many of these factors are beyond anyone's control.

Research has identified several key factors that increase the likelihood of birth fractures. These factors often interact with each other, meaning that babies with multiple risk factors have a higher cumulative risk than those with just one. However, it's important to note that fractures can occur even when no obvious risk factors are present.

Macrosomia (Large Birth Weight)

Babies with birth weights exceeding 4,000 grams (approximately 8 pounds, 13 ounces) are at significantly higher risk for birth fractures. The larger the baby, the more difficult the passage through the birth canal becomes. Large babies are more likely to experience shoulder dystocia, where the shoulders become stuck after the head is delivered, requiring additional maneuvers that can stress the bones.

The relationship between birth weight and fracture risk is well-established in medical literature. Studies have shown that babies weighing over 4,500 grams have a fracture risk several times higher than average-weight babies. Factors that contribute to macrosomia include maternal diabetes, excessive gestational weight gain, post-term pregnancy, and genetic factors.

Shoulder Dystocia

Shoulder dystocia is an obstetric emergency that occurs when the baby's shoulders become stuck behind the mother's pubic bone after the head has been delivered. This complication requires quick action from the delivery team to prevent harm to both mother and baby. The maneuvers used to free the shoulders can sometimes result in clavicle or humerus fractures.

Healthcare providers are trained in various techniques to resolve shoulder dystocia, including the McRoberts maneuver (hyperflexing the mother's legs), suprapubic pressure, and rotating the baby's shoulders. While these techniques are designed to minimize trauma, the urgency of the situation and the forces involved can sometimes lead to bone injuries.

Breech Presentation

In a breech presentation, the baby enters the birth canal feet or buttocks first instead of head first. This abnormal positioning can complicate delivery and increase the risk of fractures, particularly to the femur and humerus. When the baby's legs or arms are manipulated during breech delivery, the bones can be subjected to forces that cause fractures.

Due to the increased risks associated with breech delivery, many healthcare providers recommend cesarean section for breech babies. However, vaginal breech delivery may still be appropriate in certain circumstances when performed by experienced providers. The decision involves weighing the risks and benefits for each individual case.

Instrumental Delivery

The use of forceps or vacuum extractors to assist delivery can increase the risk of birth fractures. Forceps, in particular, have been associated with skull fractures and clavicle fractures. These instruments are used when delivery needs to be expedited or when the mother is having difficulty pushing the baby out, often due to exhaustion or medical concerns.

While instrumental deliveries carry some risks, they are sometimes necessary to prevent more serious complications. Healthcare providers carefully weigh the benefits of assisted delivery against the potential risks, and instruments are used only when medically indicated. Modern techniques and training have helped reduce complication rates from instrumental deliveries.

What Are the Symptoms of Newborn Bone Fractures?

Signs of a newborn bone fracture include reduced or absent movement of the affected limb, crying when the area is touched or during handling, swelling at the fracture site, an asymmetric Moro (startle) reflex, and sometimes a crackling sensation (crepitus) when touched. Some fractures may not be immediately apparent.

Recognizing a bone fracture in a newborn can be challenging because babies cannot verbalize their pain. Instead, parents and healthcare providers must rely on observational signs and changes in the baby's behavior. Some fractures are apparent immediately after birth, while others may not become evident until hours or even days later when swelling develops or when movement patterns are observed.

It's important for parents to understand that newborns experience pain differently than older children and adults. While they certainly feel discomfort, their pain responses may be less specific. A baby with a fracture may cry more than usual, have difficulty settling, or show feeding problems. These general signs, combined with more specific symptoms, help healthcare providers identify potential fractures.

The symptoms vary somewhat depending on which bone is affected. Clavicle fractures, being the most common, have a characteristic presentation that differs from long bone fractures. Understanding these differences can help parents know what to look for and when to seek medical attention.

Clavicle Fracture Signs

Clavicle fractures often present with a distinctive pattern of symptoms. Parents may notice that the baby does not move one arm as much as the other, particularly avoiding raising the arm on the affected side. The baby may cry when picked up under the arms or when the affected shoulder is touched. A small lump may become visible over the collarbone as the healing process begins, which is actually a positive sign indicating that bone callus is forming.

One of the most telling signs of a clavicle fracture is an asymmetric Moro reflex. The Moro reflex is a normal newborn response where the baby throws out both arms symmetrically when startled. If one arm does not extend as fully or quickly as the other, this asymmetry may indicate a clavicle or arm injury on that side. Healthcare providers routinely check for this reflex during newborn examinations.

Long Bone Fracture Signs

Fractures of the humerus (arm) or femur (leg) typically present with more obvious symptoms than clavicle fractures. The affected limb may appear swollen, and there may be visible deformity in severe cases. The baby will usually cry when the limb is moved and may keep it in a protective position. With femur fractures, parents may notice that the baby does not kick the affected leg normally.

Crepitus, a crackling or grating sensation felt when the fracture site is touched, is a classic sign of a bone fracture. However, healthcare providers must examine the baby gently to avoid causing additional pain or displacement of the fracture. In most cases, the diagnosis is confirmed with imaging rather than relying solely on physical examination findings.

When Symptoms May Be Delayed

Some newborn fractures are not immediately apparent and may only be discovered during routine examinations or when symptoms develop over the first few days of life. This is particularly true for minor fractures or those in less obvious locations. Parents should contact their healthcare provider if they notice any new symptoms or changes in their baby's behavior or movement patterns in the days following birth.

• Reduced movement: The baby does not move one arm or leg as much as the other
• Pain response: Crying when the affected area is touched or during diaper changes/dressing
• Swelling: Visible puffiness or enlargement at the fracture site
• Asymmetric reflexes: Uneven startle response or limb positioning
• Feeding difficulties: Discomfort during breastfeeding if shoulder is affected

How Are Newborn Bone Fractures Diagnosed?

Diagnosis typically involves physical examination followed by imaging studies. X-rays are the primary diagnostic tool, clearly showing fracture type and location. Ultrasound may be used as a radiation-free alternative, particularly for clavicle fractures. Physical signs include reduced movement, swelling, and pain on examination.

The diagnosis of a newborn bone fracture usually begins with clinical suspicion based on risk factors during delivery and observed symptoms in the baby. Healthcare providers conduct a thorough physical examination, paying close attention to limb movement, symmetry, and the baby's response to gentle manipulation. The examination is performed carefully to minimize discomfort while gathering the necessary diagnostic information.

Physical examination alone is often sufficient to suspect a fracture, but imaging studies are typically needed to confirm the diagnosis and determine the exact nature of the injury. The type and location of the fracture guide treatment decisions, so accurate imaging is important. Different imaging modalities have their own advantages and are chosen based on the clinical situation.

In many cases, particularly with clavicle fractures, the diagnosis is straightforward and can be confirmed quickly. More complex or unusual fractures may require additional evaluation or specialist consultation to ensure proper management.

Physical Examination

The physical examination begins with observation of the baby's spontaneous movements and positioning. Healthcare providers look for asymmetry in limb movement and positioning, which may indicate injury on one side. The Moro reflex is tested to check for symmetric arm movement, and the baby's response to gentle handling of each limb is assessed.

Palpation (gentle feeling) of suspected fracture sites may reveal tenderness, swelling, or crepitus. With clavicle fractures, a step-off or irregularity may be felt along the normally smooth collarbone. The provider also checks for any associated injuries, such as brachial plexus nerve damage that can sometimes accompany clavicle fractures.

Imaging Studies

X-rays are the gold standard for diagnosing bone fractures. They clearly show the location and type of fracture, allowing healthcare providers to plan appropriate treatment. The radiation exposure from a single X-ray is very low and considered safe for newborns when medically indicated. X-rays can also help rule out other conditions that might cause similar symptoms.

Ultrasound has emerged as a valuable alternative for diagnosing certain newborn fractures, particularly clavicle fractures. Ultrasound uses sound waves rather than radiation, making it an attractive option for radiation-conscious parents. It can effectively visualize the fracture and surrounding soft tissues. However, X-rays remain preferable for some fracture types and locations.

In rare cases, additional imaging such as CT scans or MRI may be needed for complex fractures or when there are concerns about associated injuries. These advanced imaging modalities are used selectively due to their higher cost, longer examination time, and in the case of CT, higher radiation exposure.

How Are Newborn Bone Fractures Treated?

Treatment for newborn bone fractures is usually conservative, involving gentle handling, positioning, and pain management. Clavicle fractures typically require only pinning the affected arm to the body. Long bone fractures may need soft splinting or a Pavlik harness. Surgery is rarely necessary. Most fractures heal completely within 2-4 weeks.

The treatment of newborn bone fractures takes advantage of the remarkable healing capacity of infant bones. Unlike adult fractures, which often require casting or surgical fixation, newborn fractures typically heal with minimal intervention. The high concentration of growth factors and the active bone remodeling that occurs in infancy allow for rapid and complete healing in most cases.

The primary goals of treatment are to relieve pain, support healing, and prevent complications. This is achieved through a combination of positioning, gentle handling techniques, and when necessary, pain medication. Parents play a crucial role in treatment by learning how to handle their baby safely and comfortably during the healing period.

The specific treatment approach depends on the location and severity of the fracture. While the principles are similar across fracture types, each has some unique considerations that guide management decisions.

Treatment for Clavicle Fractures

Clavicle fractures are the simplest to treat and have the best outcomes. In most cases, the only treatment needed is to immobilize the arm on the affected side by pinning it gently to the body. This can be done simply by tucking the arm inside the baby's clothing or by pinning the sleeve to the shirt. Some providers may recommend a figure-of-eight bandage, though this is becoming less common.

Parents are taught to handle the baby carefully, avoiding lifting under the arms and supporting the affected side when picking up the baby. During feeding, the baby should be positioned to avoid pressure on the fractured clavicle. The football hold during breastfeeding may be more comfortable than traditional cradle holds.

Healing typically occurs within 2-3 weeks for clavicle fractures. A visible and palpable lump (callus) often forms at the fracture site as healing progresses, which is normal and will gradually remodel over several months to years until it's no longer noticeable.

Treatment for Long Bone Fractures

Humerus and femur fractures require somewhat more involved treatment than clavicle fractures, though the approach remains conservative in most cases. The affected limb may be immobilized with a soft splint or bandaging. For femur fractures, a Pavlik harness (similar to those used for hip dysplasia) may be used to hold the leg in a comfortable position while healing occurs.

Parents receive detailed instructions on caring for their baby during the healing period. Diaper changes and bathing require extra care to avoid moving the affected limb unnecessarily. Healthcare providers may demonstrate specific techniques for handling that minimize discomfort and protect the healing bone.

Long bone fractures typically heal within 3-4 weeks in newborns. Follow-up X-rays or ultrasounds may be performed to confirm proper healing and alignment. In the rare case that a fracture does not heal properly or is significantly displaced, orthopedic consultation may be needed.

Pain Management

Pain control is an important aspect of treating newborn fractures. While newborns cannot verbalize their pain, they certainly experience discomfort and deserve appropriate pain management. Non-pharmacological measures such as gentle swaddling, skin-to-skin contact, and breastfeeding can help soothe the baby and reduce pain perception.

When medication is needed, infant-appropriate acetaminophen (paracetamol) may be prescribed. The dosage is carefully calculated based on the baby's weight. Parents should follow dosing instructions precisely and not give additional pain medications without consulting their healthcare provider. Most babies need pain medication only for the first few days after the fracture is diagnosed.

How Do I Care for My Baby at Home?

Home care involves gentle handling, supporting the affected limb, careful feeding positions, and monitoring for pain. Pick up your baby by supporting under the back and buttocks rather than under the arms. During diaper changes, be extra gentle with leg movements. Use comfortable feeding positions that avoid pressure on the fracture site.

Caring for a newborn with a bone fracture at home can feel overwhelming at first, but with proper guidance, most parents quickly become comfortable with the necessary techniques. The key is to move slowly and gently, always supporting the affected area and watching your baby's cues for discomfort. Within a few days, both you and your baby will adapt to the temporary limitations.

Remember that newborn bones heal remarkably quickly, and the special handling requirements are temporary. Most parents find that by the time their baby is 2-3 weeks old, the fracture has healed sufficiently that normal handling can resume. During the healing period, maintaining close contact with your healthcare provider ensures any concerns are addressed promptly.

Handling and Positioning

When picking up your baby, always support the affected limb. For clavicle fractures, avoid lifting under the arms; instead, scoop under the baby's back and buttocks while supporting the head. Keep the affected arm tucked against the body when moving your baby. When putting your baby down, lay them on their back and avoid rolling them onto the affected side.

Sleep positioning should follow standard safe sleep guidelines (on the back, on a firm surface) while also considering the fracture location. Most babies naturally find comfortable positions that protect the injured area. Swaddling can provide comfort but should be done gently, ensuring the affected limb is in a neutral, comfortable position.

Feeding Considerations

Feeding can require some adjustments when your baby has a fracture. For breastfeeding mothers with a baby who has a clavicle fracture, the football hold (baby's body along your side) often works better than the traditional cradle hold, as it avoids putting pressure on the affected shoulder. Experiment with different positions to find what's most comfortable for your baby.

Bottle-feeding parents should similarly find positions that avoid pressure on the fracture site. Supporting the baby's body with pillows can help you maintain a comfortable position for longer feeds. Watch for signs of discomfort during feeding and adjust positioning as needed.

Diaper Changes and Bathing

Diaper changes require extra care when your baby has a fracture, particularly for leg fractures. For femur fractures, lift your baby's bottom by sliding your hand under the lower back rather than lifting by the legs. For arm fractures, be mindful of not jostling the affected arm when maneuvering during diaper changes.

Bathing can continue during the healing period, but should be done carefully. Sponge baths may be easier than full baths during the first week or two. If your baby has a splint or special bandaging, follow your healthcare provider's instructions about keeping it dry. When bathing, support the affected limb throughout the process.

What Is the Long-Term Outlook?

The prognosis for newborn bone fractures is excellent. Nearly all fractures heal completely within 2-4 weeks without any long-term complications. A small bump may remain at the fracture site temporarily but usually disappears within months. Complications are rare and most children have no lasting effects from their birth fracture.

Parents understandably worry about the long-term effects of a birth fracture on their child. The reassuring news is that newborn bone fractures have an excellent prognosis. The combination of the baby's rapid growth rate, active bone remodeling, and the straightforward nature of most birth fractures means that complete healing without lasting consequences is the norm rather than the exception.

The healing process in newborns is remarkably efficient compared to older children and adults. Newborn bones are rich in growth factors and have an abundant blood supply, both of which promote rapid healing. Additionally, the ongoing growth and remodeling of bones during childhood means that even minor imperfections in initial healing are usually corrected naturally over time.

Medical research has consistently shown that children who experienced birth fractures have normal development and function as they grow. Long-term follow-up studies have found no significant differences in strength, mobility, or bone health compared to children who did not have birth fractures. This should provide comfort to parents concerned about their child's future.

The Healing Process

Bone healing in newborns follows a predictable pattern. Initially, the body forms a soft callus of cartilage-like tissue at the fracture site. This callus is often visible as a small bump, particularly with clavicle fractures. Over the following weeks, this soft callus is gradually replaced by hard bone in a process called ossification.

The visible bump typically persists for several weeks to months after the fracture has healed. Parents sometimes worry about this lump, but it is actually a sign of healthy healing. Over time, the body remodels this excess bone, and the bump gradually becomes smaller and eventually disappears. In rare cases, a very small, barely noticeable bump may persist into adulthood, but this causes no functional problems.

Possible Complications

While complications from newborn fractures are uncommon, parents should be aware of potential issues that might arise. The most common concern is malunion, where the bone heals in a slightly abnormal position. In newborns, even moderate malunion often corrects itself with continued growth, and significant malunion requiring treatment is rare.

Brachial plexus injury (nerve damage to the arm) can occur alongside clavicle fractures due to the anatomical proximity of the nerves and the clavicle. If present, this nerve injury is usually mild and recovers on its own within weeks to months. Signs include weakness or reduced movement of the affected arm beyond what would be expected from the fracture alone. Your healthcare provider will monitor for this during follow-up visits.

Follow-Up Care

Your healthcare provider will schedule follow-up appointments to monitor healing progress. These visits may include physical examination to assess movement and comfort, and sometimes repeat imaging to confirm proper healing. Most babies need only one or two follow-up visits to confirm that healing is proceeding normally.

If you notice any concerns between scheduled appointments, don't hesitate to contact your healthcare provider. Signs that warrant prompt evaluation include increased fussiness, reduced movement of the affected limb after initial improvement, fever, or any new symptoms. Early evaluation of concerns helps ensure optimal outcomes.

Can Birth Fractures Be Prevented?

While not all birth fractures can be prevented, risk can be reduced through careful prenatal monitoring, appropriate management of macrosomia and diabetes, skilled delivery techniques, and appropriate planning for high-risk deliveries. However, some fractures occur even with optimal care due to the unpredictable nature of childbirth.

Prevention of birth fractures is a complex topic because it involves balancing multiple factors during delivery. Healthcare providers continuously assess the risks to both mother and baby and make decisions aimed at achieving the best outcome for both. While certain measures can reduce fracture risk, the goal is always to minimize overall harm, which sometimes means accepting some risk of minor injuries like fractures to avoid more serious complications.

Understanding what can and cannot be controlled helps parents process their experience and reduces feelings of guilt if a fracture does occur. Many risk factors for birth fractures, such as the baby's size or position, are not within anyone's control. Others, like the decision to use instruments during delivery, represent necessary interventions to prevent worse outcomes.

Prenatal Measures

Good prenatal care can help identify risk factors for difficult delivery and birth fractures. Regular ultrasound examinations allow healthcare providers to estimate the baby's size and identify potential macrosomia. For mothers with diabetes, careful blood sugar control helps reduce the likelihood of having a very large baby. When macrosomia is identified, providers can discuss delivery options and plans.

Fetal position is monitored throughout pregnancy, and breech presentation is typically identified well before the due date. For babies in breech position, providers may discuss options including external cephalic version (manually turning the baby) or planned cesarean delivery. These discussions allow families to make informed decisions about their birth plan.

During Delivery

Skilled obstetric care is the primary means of preventing birth fractures during delivery. Healthcare providers are trained in techniques to minimize trauma while ensuring safe delivery of the baby. When shoulder dystocia occurs, specific maneuvers are employed in a systematic way to resolve the emergency with minimal harm.

The decision to use instruments (forceps or vacuum) or to proceed with cesarean delivery involves careful consideration of risks and benefits. In some situations, the risk of fracture with vaginal delivery is accepted because it is lower than the risks associated with emergency cesarean section. These complex decisions are made in real-time by experienced providers.

When Prevention Isn't Possible

Despite all precautions, some birth fractures cannot be prevented. The forces involved in childbirth are significant, and the unpredictable nature of labor means that complications can arise unexpectedly. Parents should understand that a birth fracture does not mean that something was done wrong; it is sometimes an unavoidable result of the birthing process.

Healthcare providers take these injuries seriously and work to minimize their occurrence. However, the primary goal of obstetric care is to deliver a healthy baby safely, and sometimes minor injuries like fractures occur even with the best care. The excellent prognosis for these injuries means that the long-term impact on the child is negligible.