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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 104-106

Management of a neonatal femoral shaft fracture following breech presentation: A case report


1 Department of Paediatrics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Orthopaedics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
3 Department of Obstetrics and Gynaecology, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Date of Submission24-Dec-2020
Date of Acceptance13-Apr-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Sqn Ldr (Dr) Mahesh D Awariwar
Department of Paediatrics, INHS Kalyani, Visakhapatnam - 530 005, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_193_20

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  Abstract 


Birth injuries, including long bone fractures, are most often observed following breech delivery or difficult deliveries. Although a long bone fracture is a relatively rare complication, femoral fractures constitute one of the most common forms of injury of the lower extremity presenting in newborns. A low birth weight, female neonate was delivered by C-section with breech presentation in utero and presented with swelling and abnormal mobility of the right thigh immediately after birth. The femoral shaft fracture was successfully treated by conservative management using a Pavlik harness for 6 weeks. Even though cesarean deliveries reduce traumatic complications, especially in breech presentations, compared with vaginal delivery, they do not completely eliminate the possibility of accidental injuries to the newborn.

Keywords: Breech presentation, femoral shaft fracture, neonate, Pavlik harness


How to cite this article:
Awariwar MD, Iqbal MS, Jayamol M A, Bhat V. Management of a neonatal femoral shaft fracture following breech presentation: A case report. J Mar Med Soc 2022;24, Suppl S1:104-6

How to cite this URL:
Awariwar MD, Iqbal MS, Jayamol M A, Bhat V. Management of a neonatal femoral shaft fracture following breech presentation: A case report. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 9];24, Suppl S1:104-6. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/104/336190




  Introduction Top


Injuries during childbirth birth are rare, occurring in <1% of live births. These are usually associated with breech presentation and difficult labor. Long bone fractures in lower extremities are even less common. Majority of neonatal femoral fractures occur during assisted vaginal deliveries.[1] It has been observed that planned cesarean sections reduce the risk of fractures of long bones, including the femur, but do not eliminate this possibility. With appropriate management, these injuries have shown rapid healing within a short span of time.[2]

We present a case of fracture shaft of femur in a newborn, following a C-section due to breech presentation.


  Case Report Top


The pregnancy of the index case was booked in the antenatal clinic at 3 months of gestation with initial antenatal scans being normal. The mother was diagnosed as a case of pregnancy-induced hypertension at 30 weeks of gestation and tablet labetalol 100 mg once a day was started, following which she was on regular follow-up with her obstetrician. Her clinical profile and laboratory parameters were within normal limits.

The expectant mother was admitted at 36 weeks gestation for a planned lower segment cesarean section in view of her raised blood pressure and breech presentation. The baby, a female, was delivered through a lower segment transverse cesarean section. The obstetrician did not encounter any difficulty in delivering the baby. While delivering the baby's right leg, the obstetrician felt a snapping sound in the thigh. The baby cried after birth, had normal Apgar scores, and was noted to have a birth weight of 2400 g.

Immediately after the delivery, the obstetrician observed a swelling in the right thigh of the newborn. On detailed examination, the newborn baby was noted to have normal tone, swelling of the right thigh, pain on handling/movement, and abnormal mobility in the swelling. After initial neonatal care, the baby was shifted to the neonatal intensive care for further assessment and management. X-rays of the affected thigh revealed a fracture of the right femoral shaft at the junction of the upper one-third with the lower two-third along with bayonet apposition of the fracture fragments. X-ray also confirmed this isolated diaphyseal injury not involving the growth plate/epiphysis [Figure 1] and [Figure 2]. There was no evidence of any other fracture or bony deformity. She was started on injectable analgesics, feeds, and supportive care.
Figure 1: Infant with Fracture Femur (Erect)

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Figure 2: Infant with Palvik Harness

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Orthopedic consultation was sought, and the neonate was planned to be managed conservatively using a Pavlik harness for 6 weeks. The baby was discharged home on day 3 of life with the mother having been trained in caring for the baby and in application and adjustment of the harness [Figure 3].
Figure 3: Infant with Palvik Harness (Sitting)

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The neonate was followed up weekly in the pediatric and orthopedic outpatient departments. Callus formation was noticed at about day 21. At the time of last follow-up, there was complete consolidation at the fracture site, along with no rotational deformity or limb length discrepancy vis a vis the opposite normal limb [Figure 4]. There were no complications noted with application of the Pavlik harness.
Figure 4: Infant with Healed Fracture Femur (Sitting and Erect)

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  Discussion Top


Literature describes various risk factors which increase the incidence of neonatal birth trauma, including large or very small babies, breech presentation, inadequate uterine relaxation, difficult delivery, small uterine incision, twin/multiple gestation, prematurity, advanced maternal age, primipara status, osteogenesis imperfecta, and osteoporosis.[3],[4],[5] Long bone fractures have often been attributed to difficult deliveries, mainly in breech presentation.[1] Those with femoral fractures were more often associated with twin deliveries, low birth weight, and small for gestational age babies.[1]

Basha et al.[2] found that long bone fractures in newborns were more often associated with cesarean breech deliveries, vis a vis vaginal delivery. They found that the incidence of birth-related femoral fractures was 0.17 per 1000 live births.

The index case was diagnosed immediately after birth. Time at diagnosis has averaged 6.3 days as published by Högberg et al.[1] and 1.5 days as per Basha et al.[2] The delay in diagnosis may be due to the fact that signs such as soft-tissue swelling, joint stiffness, focal tenderness, and irritability appear later than usual in neonates. The recommended and common treatment options available for femoral fractures in neonates include posterior limb splinting, spica cast application, gallows traction, Bryant's traction, and Pavlik harness application.[6] All these modalities give good clinical and radiological results within 1 month after injury, with no major complications reported.

Many approaches are available for the management of femoral neonatal fractures. Only separation of distal femoral epiphysis or extreme epiphyseal displacement can require intervention in the event of instability. The function of Bryant's and gallow's methods of traction is to provide an easy means of managing femoral shaft fractures in children from neonatal period to the age of approximately 4 years. However, the problems associated with these methods involve prolonged immobilization in a bed, either in a hospital or home-based traction unit, which is rather expensive and cumbersome in a third-world setting. In additon, if unsupervised, complications such as skin irritation and dermatitis, sciatic nerve palsy, and malunion due to rotational or angular malalignment are common. The use of Pavlik brace in infants with femoral fractures is easier to apply, avoiding skin irritation and prevent complications arising from the conventional traction methods.

Our case was managed with Pavlik harness application. This modality of treatment manages reduction of the fracture by appropriate adjustment of the straps in the harness, which was described by Kancherla et al.[6] In addition, it reduces the requirement for a prolonged hospital stay. The index case was discharged 2 days after application of the harness. Strapping with a Pavlik harness thus has the advantages of low cost, simplicity of application, adjustability, and ease of reduction and maintenance of perineal hygiene with ease.


  Conclusion Top


The clinician must be cognizant that cesarean section does not eliminate the occurrence of long bone fractures. The risk factors include breech presentation, multiple pregnancies, and large or small for gestation. Neonatal femoral fractures can be successfully treated without complications within a short period of time by using a Pavlik harness, ensuring a good and uncomplicated recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Högberg U, Fellman V, Thiblin I, Karlsson R, Wester K. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures. Acta Paediatr 2020;109:2040-8.  Back to cited text no. 1
    
2.
Basha A, Amarin Z, Abu-Hassan F. Birth-associated long-bone fractures. Int J Gynaecol Obstet 2013;123:127-30.  Back to cited text no. 2
    
3.
Mavrogenis AF, Mitsiokapa EA, Kanellopoulos AD, Ruggieri P, Papagelopoulos PJ. Birth fracture of the clavicle. Adv Neonatal Care 2011;11:328-31.  Back to cited text no. 3
    
4.
Ozdener T, Engin-Ustun Y, Aktulay A, Turkcapar F, Oguz S, Yapar Eyi EG, et al. Clavicular fracture: Its incidence and predisposing factors in term uncomplicated pregnancy. Eur Rev Med Pharmacol Sci 2013;17:1269-72.  Back to cited text no. 4
    
5.
Rahul P, Grover AR, Ajoy SM. Bilateral humerus and right femur fracture in a newborn after cesarean section for breech presentation in a twin pregnancy: A very rare case report. J Orthop Case Rep 2017;7:9-11.  Back to cited text no. 5
    
6.
Kancherla R, Sankineani SR, Naranje S, Rijal L, Kumar R, Ansari T, et al. Birth-related femoral fracture in newborns: Risk factors and management. J Child Orthop 2012;6:177-80.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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