What is the recommended follow-up imaging for a neonatal clavicle fracture?

Follow-Up Imaging for Neonatal Clavicle Fractures

For neonatal clavicle fractures, ultrasound is the recommended follow-up imaging modality as it provides radiation-free assessment of fracture healing and can detect consolidation earlier than radiographs.

Initial Assessment and Diagnosis

Neonatal clavicle fractures are the most common birth-related bony injuries, with an incidence of 0.35-2.9% of births 1. Up to 40% remain undetected at hospital discharge. Initial diagnosis may be based on:

• Clinical findings:

  • Palpable spongy mass over the clavicle (present in 82% of cases) 2
  • Crepitus (45% of cases) 2
  • Asymmetric Moro reflex
  • Angulation deformity (9% of cases) 2
  • Localized tenderness (5% of cases) 2
  • Pseudoparalysis of the affected arm

• Initial imaging:

  • Radiographs are typically used for initial diagnosis confirmation
  • Ultrasound can also provide initial diagnosis with comparable accuracy 3, 4

Follow-Up Imaging Recommendations

Ultrasound Follow-Up (Preferred Method)

Ultrasound offers significant advantages for follow-up imaging of neonatal clavicle fractures:

1. Radiation-free assessment: Eliminates exposure to ionizing radiation in this vulnerable population 3, 4

2. Earlier detection of healing: Ultrasound can detect stress-resistant, stable healing of tissue approximately one week before radiographs show any signs of bone healing 3

3. Earlier detection of complications: Consolidation disorders such as early signs of pseudarthrosis can be detected earlier with ultrasound 3

4. Practical benefits:

   • Simple to perform 4
   • Reduces duration of immobilization 3
   • Decreases frequency and number of follow-up examinations 3
   • Cost-effective 3

Technique for Ultrasound Assessment

• Longitudinal scans of the bone by directing the probe along the clavicle's axis 4
• Can be performed without sedation 5

When Skeletal Survey Is Indicated

According to pediatric guidelines, a skeletal survey (SS) is generally not necessary for isolated neonatal clavicle fractures when birth trauma is the clear etiology 6:

• For infants ≤10 days old with an acute clavicle fracture and no history of trauma (other than birth trauma), skeletal survey is of "uncertain appropriateness" 6
• For infants 11-21 days old with acute fractures, skeletal survey is "appropriate but not necessary" 6
• For infants <30 days old with healing fractures, skeletal survey is "appropriate but not necessary" 6

Timing of Follow-Up

• Initial follow-up ultrasound can be performed approximately 1-2 weeks after diagnosis
• Additional follow-up may be determined based on healing progress

Clinical Course and Parent Communication

• Parents should be reassured that healing will occur without medical intervention and without residual deformity 1
• Complete healing typically occurs within 3-4 weeks
• Careful documentation is important for medico-legal aspects 1

Pitfalls to Avoid

1. Misdiagnosis: Medial clavicular physeal fractures can mimic sternoclavicular dislocation on radiographs; ultrasound can help differentiate these conditions 5

2. Unnecessary radiation: Avoid repeated radiographs when ultrasound can provide adequate follow-up information 3, 4

3. Missed diagnosis: Relying solely on asymmetric Moro reflex or visible swelling/bruising may lead to missed fractures; the palpable spongy mass is a more reliable sign 2

4. Unnecessary skeletal surveys: In clear cases of birth-related trauma, extensive skeletal surveys are generally not indicated for isolated clavicle fractures in neonates 6