Chiropractic management of musculoskeletal disorders associated with a neonatal clavicle fracture: a case report

By Amelie Bourque, DC¹

1. Private practice, Montreal, Quebec, Canada
Email: bourque.amelie@hotmail.com

ABSTRACT

Objective: To present chiropractic management of a 5-month-old patient with multiple complaints related to a neonatal clavicle fracture and the resolution of all symptoms after 4 treatments. Case presentation: A 5-month-old male presenting with history of a fractured left clavicle, fussing, irritability, crying, grunting, rigidity, abnormal positioning of his left arm at rest, breastfeeding difficulties on the right side and apparent discomfort lying on his stomach. He presented to a chiropractic office after consulting various health professionals without improvement. Interventions, and outcomes: Various techniques, including touch and hold, sacro-occipital, light vibration and mobilization were used to treat the 5-month-old male infant during the 4 visits complimented by home exercises. Objective findings of subluxations of the left clavicle, left 1st rib, T2, T5, occiput, left scapula and left gleno-humeral joint were confirmed with static palpation, motion palpation of the spine and the upper limb. Following 4 visits, grunting and crying ceased, the left arm was in normal position at rest with complete active and passive range of motion, breastfeeding successfully bilaterally without nipple pain for the mother. The child also demonstrated improvement in motor development. Conclusion: Chiropractic management should be considered collaboratively with medical follow-up in cases of birth trauma such as clavicle fracture. Further research is warranted to asses the long-term musculoskeletal sequelae with similar cases of neonatal birth trauma.

Key Words: case report, chiropractic, subluxation, neonatal clavicle fracture, footling breech presentation, birth trauma, Caesarean section, breastfeeding difficulties, irritability, sleep disorder.

Introduction
Neonatal clavicle fracture is defined as a trauma directly related to vaginal delivery or caesarean section.¹ It is considered as the most commonly fractured bone in obstetrics, occurring in 0.2% to 3.5% of all births.^1-3 Usually seen during vaginal deliveries, clavicle fractures in newborns are associated with shoulder dystocia, birth weight, vacuum deliveries, prolonged second stage of labor, gestational age, instrumental vaginal delivery, maternal age, height and obesity.^2,3 Generally associated with a lower risk of birth trauma, clavicle fractures can also occur during caesareans.⁴ A retrospective review of caesarean deliveries with neonatal clavicle fracture identified an incidence of 0.05% for this birth trauma.² In both, vaginal or caesarean deliveries, pathophysiology of the clavicle fracture is still unclear. Some authors associated this trauma with the pressure of the fetal shoulder on the mother’s symphysis during the contractions associated with a vaginal delivery and the baby’s birth weight with a Caesarean delivery.^2,3 Considering previous studies, prognosis of clavicle fractures is benign without sequelae and without requiring treatment.^2,3 Neurological injuries associated with clavicle fracture, such as brachial plexus palsy, are well documented as possible outcomes. But there is no current study presenting the possibility of musculoskeletal sequelae associated with birth trauma.

Diagnosis is usually confirmed with physical examination and radiography. Principle signs of a clavicle fracture in a newborn patient included swelling, asymmetric Moro reflex, tenderness, crepitation in the affected shoulder and crying when the affected upper arm is moved.^3,5 Neonatal clavicle fractures can be undiagnosed at birth and only confirmed during the days following childbirth. A retrospective review demonstrated an incidence of 86.2% confirmed diagnosis before discharge from the hospital with a physical examination or radiography.³

The aim of this current case report is to present the association of neonatal clavicle fracture with musculoskeletal disorders and related effects on the physical development of the baby and his well-being.

Methods
The following electronic databases were used to identify previously published studies: Pubmed, Google Scholar, Mantis, Index to Chiropractic Literature, ICPA Research. Search keywords included: birth trauma, neonatal clavicle fracture, cesarean delivery, pediatric, chiropractic, manipulation and treatment. Supporting publications used in this paper: Case study, systematic review and retrospective review. Other books and articles were used to provide supporting information.

Case report
A 5-month-old male infant was presented by his mother for a chiropractic evaluation. Chief complaints included fussing, irritability, crying, grunting, rigidity, abnormal position of his left arm, 2 weeks of constipation, breastfeeding difficulties on the right side and apparent discomfort lying on his stomach. The mother associated all these complaints to the fracture of his left clavicle he had sustained during his birth.

The multiparous mother described her second pregnancy with some complications. At 11 week of gestation, she received a diagnosis of one healthy embryo, one non-viable embryo and a subchorionic hematoma of 5 cm located near the cervix with a recommendation of rest. At 13 week of gestation, bleeding and cramps starts related to an hypertrophy of the hematoma. At 15 week of gestation, they confirmed the presence of a second hematoma, she was put on bed rest for the remainder of her pregnancy and prescribed a prometrium treatment to avoid miscarriage risk. At 21 week of gestation, the subchorionic hematoma has resorbed but an amniotic fluid sludge was diagnosed increasing the risk of cervix inflammation and preterm labor. An antibiotic was prescribed for the mother preemptively to manage any risk of infection. At 23 week of gestation, preterm labor was no longer a risk, but the ultrasound showed a low fetal weight (in the 12th percentile). Her obstetrician recommended ultrasound every two weeks to evaluate the risk of intrauterine growth restriction. Fetal weight varied between the 5th and the 10th percentile. The baby was born at 40 week with a birth weight of 2,925g, in the 5th percentile, without any associated complication.

The baby was delivered with an emergency Caesarean section because of a footling breech presentation. At 39 weeks and 5 days of gestation, the obstetrician detected that the fetus was in a breech position. The next day, they attempted an external cephalic version to try to turn the fetus to a vertex position. At the end of the procedure, with fetal ultrasound, they confirmed the fetus was vertex with his feet close to his head. The mother chose to postpone the planned Ceasarean until 41 weeks of gestation allow for the baby to complete his version. At 40 weeks and 1 day of gestation the mother underwent a fetal ultrasound to confirm the fetal position. The fetus was in a footling breech position so they decided to schedule an emergency Caesarean the same night. Upon going home to prepare, 30 minutes after leaving the hospital, the mother had a spontaneous rupture of her membranes without any detectable uterine contractions. The contractions started naturally when she came back to the hospital 30 minutes later. Upon performing a vaginal examination, they discovered that she was dilated to 10 cm and a fetal foot had passed through the cervix. The Caesarean section immediately performed and completed in 5 minutes.

APGAR scores were 7 at 1 minute and 9 at 5th minutes, because the neonate did not cry during the first minute. The mother reported a rapid and stressful birth, 3 hours from onset to delivery. The first pediatrician did a physical exam on the neonate after 2 hours of life without noticing any abnormality. On the 4th day, a second pediatrician did a physical evaluation and detected a left clavicle fracture. The pediatrician proposed an x-ray to confirm the fracture, but parents declined it. The parents did not receive any specific recommendations for care or precautions around the clavicle fracture. The pediatrician told the parents that the fracture was benign, the prognosis was good, and that healing should occur without any risk of complication or sequelae.

The mother observed a change in her infant’s behavior after his second week of life starting with breastfeeding difficulties on the ride side, rigidity in his global tonus with a tendency to arch his back and an abnormal positioning of his left arm in extension when she was breastfeeding him. At 3 months, the mother noticed persistent grunting accentuated during tummy time and lying on the bed. The mother visited multiple health care professionals without seeing any improvements in her child

The mother noted a decrease in grunts and a stronger latch while her baby was taking acetaminophen. Medical physical assessments were normal and showed no disorders related to the clavicle fracture. However, convinced that her son was suffering because of his clavicle, the mother decided to consult a chiropractor.

Physical Exam
The infant was agitated, grunting and crying upon physical examination with evidence of rigidity in his global tonus. General posture in extension was observed. Head rotation was slightly limited to the left during passive rotation. Upon evaluating left shoulder mobility the infant was distressed and reacted by contracting the musculature around the shoulder girdle. The mother mentioned the infant always medially rotated and extended his left arm backward when she was breastfeeding him and he did not want to rest on his left arm during tummy time. Neurological examination revealed intact Galant, Babinski and Landau reflexes.

Objective findings of subluxations of the left clavicle, left 1st rib, T2, T5, occiput, left scapula and left gleno-humeral joint were confirmed with static palpation and motion palpation of the spine and the upper limb. Left clavicle was restricted in depression (supero-inferior) and protraction (postero-anterior) associated with left trapezius and scalene hypertonicity. Palpating the left first rib in sitting and supine position confirmed the important loss of supero-inferior mobility. T2 had posterior and right rotational misalignment. T5 was found posteriorly restricted with significant contracture in paraspinal musculature. Palpation of the occiput revealed a restriction in flexion with hypertonicity in suboccipital musculature. Left scapula was restricted in both internal and external rotation associated with rotator cuff musculature contracture. Left gleno-humeral joint was found to be restricted in flexion, abduction and internal rotation combined with hypertonicity of the left pectoralis major.

Diagnosis and Treatment
A pediatrician confirmed the clavicle fracture at the time of discharge from the hospital on the 4th day of life during a physical examination. Parents declined the proposed radiography because according to the doctor, the outcome would not affect the treatment plan. The significant restrictions around the left shoulder girdle, including the clavicle, scapula, gleno-humeral joint, first rib and upper thoracic were all associated to the left clavicle fracture. The chiropractic diagnosis was a left shoulder girdle dysfunction associated with a neonatal fracture of the left clavicle and multiple subluxation complexes.

The 5-month-old patient was treated by a chiropractor once a week for the first two weeks and then two more time during the next 2 months for a total of 4 visits. Chiropractic treatment was initiated following the physical examination at the first visit. Informed consent was obtained after the report of finding at the first visit. A combination of different techniques were used to treat joint restrictions. Left clavicle, 1st rib, scapula and gleno-humeral joint were adjusted with light mobilization and vibration because the area was sensitive to pressure. Sacro-occipital technic (SOT) was used to treat the occipital restriction and to release the tension in the fascia and the paraspinal musculature. Thoracic spine (T2 and T5) was treated with the “touch and hold” technique by holding a specific, light pressure on the fixated vertebrae. The left shoulder girdle musculature was treated using myofascial release and massage. The parents received home exercises recommendation to reduce tension and to improve motor development.

Outcomes
Immediately after the first treatment, the mother observed significant changes in her child’s behavior and well-being. In the following days, he was more calm and relaxed, his left arm was no longer held in extension, breastfeeding on the right side was easier with a better latch and transfer, digestion was normalized (he had been constipated for the last two weeks), less grunting, more easily consoled and more comfortable in tummy time. At the 3rd visit, it was noted that there was no more grunting, no more crying during the tummy time and he was able to sit unassisted. After the 4th and last visit, he had normal range of motion of his left upper limb without hypertonicity in the musculature around the shoulder girdle, no residual breastfeeding issues, radically positive changes in his motor development, staying longer in the prone position, sitting by himself and crawling. The mother confirmed he was no longer grunting or crying for inexplicable reasons. Chiropractic care was concluded after the 4th visit because parents moved to another city but they were greatly encouraged to continue treatment in another chiropractic clinic as needed. The parents reported no adverse events related to any of the treatments given.

Discussion
In utero, the first bone to ossify is the clavicle and it is the most commonly fractured bone at birth. Usually, birth related clavicle fractures are nondisplaced greenstick type fractures and can be confirmed with “crunchiness” upon palpation of the clavicle. Complete healing of the clavicle fracture takes about 2 to 3 weeks and during this period, parents should avoid lifting the child by the arm to prevent aggravation of the injury.⁶ Sometimes, pediatricians will recommend bracing to stabilize the clavicle but in most cases no treatment is needed.⁷

In this case, parents did not receive any recommendations before leaving the hospital on the specific care of a clavicle fracture. Even without serious neurological sequelae associated with the clavicle fracture, parents should be advised of the precaution they need to take with their newborn. Specific recommendations include handling their baby gently, avoid pulling the arm to lift the baby and to avoid lying baby on the affected side in his bed and also during breastfeeding.^8,9 With these recommendations, parents could have avoided positioning their baby on the affected side, which would have made breastfeeding easier and less painful for the infant and the mother. Right breastfeeding was very difficult suggesting the position was painful for the baby.

Many studies on clavicle fractures have been reported and there is no report of frequent complications. In some case, brachial plexus palsy with limited movement of the wrist and arm and phrenic nerve paralysis were associated with the fracture but the patient had no related sequelae.^3,7,8 There is limited information concerning long-term sequelae associated with neonatal clavicle fracture. Biomechanical dysfunctions such as restricted joint mobility, muscles tenderness, sensitivity and limited range of motion (ROM) are not directly associated to the clavicle fracture in the literature. However, in this case, the patient had several biomechanical constraints associated with the birth trauma. Decreased ROM of the glenohumeral, scapulothoracic and sternoclavicular joints, multiple joint restrictions mainly at the left first rib and clavicle, hypertonicity and tenderness of left shoulder girdle muscles all could potentially have been associated with the trauma that caused the original clavicle fracture. Despite orthopedic management of the bone fracture, patients who had neonatal clavicle fracture should also being seen by a chiropractor. Chiropractic analysis was essential to diagnose of a left shoulder girdle dysfunction associated with a neonatal fracture of the left clavicle and multiple subluxation complexes. Contrary to what we found in the literature, this case suggested that patients could have associated sequelae.

Spear and Alcantara¹⁰ presented a study of a 6-week-old infant born with trauma from vacuum extraction under chiropractic care. A male infant presented with chief complaint of infantile colic, acid reflux, restlessness, inability to relax and/or lay on his back, difficulty sleeping and general irritability. The patient had 7 treatments of chiropractic care using Activator and “touch and hold” adjustments. Following these 7 treatments, the mother noticed improvement of the initial complaints and resolution of his digestive problems.

In this case report, restoration of normal ROM of the left clavicle, first rib, shoulder girdle, cranial bones and thoracic spine through chiropractic adjustments allowed an improvement in the child posture, motor development, breastfeeding and well-being. Chiropractic adjustment can be considered safe when modified or adapted for infants with the absence of adverse event following low force adjustment.^11,12

In conclusion, this case report demonstrates the importance of chiropractic follow-up after a birth trauma such as neonatal clavicle fracture. Chiropractic assessment evaluates biomechanics and neuromusculoskeletal system to determine whether or not there are possible sequelae following a birth trauma. Considering the positive results following chiropractic treatment in this case, chiropractic could be considered as a gentle, safe and modifiable approach to treat infants with co-morbid conditions associated with a clavicle fracture. There is undeniably a significant lack of resources on this subject and more research is needed to support knowledge on chiropractic care of musculoskeletal sequelae associated to a clavicle fracture.

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11. Vallone SA, Miller JE, Larsdotter A, Barham-Floreani J. Chiropractic approach to the management of children. Chiropractic & Osteopathy 2010;18(16).

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