JANUARY 2022 Question: A two-hour-old term neonate has decreased movement of her left arm in the newborn nursery. Her mother’s pregnancy was complicated by obesity and gestational diabetes. She was delivered vaginally with vacuum assistance. Agape scores were eight and nine at one and five minutes, respectively. She weighs 4.6 kg. Physical examination findings are notable for a comfortable-appearing, macrosomic neonate with left posterior cephalohematoma, no crepitus of the clavicle, absent left Moro reflex, no movement against gravity of the left arm, positive left hand grasp, and active movement of the right arm and lower extremities. Sensation appears intact in all extremities. The remainder of the physical examination findings is normal. Look at the chest radiograph: Of the following, the BEST next step in management of this neonate is A. left arm immobilization B. left arm muscle biopsy C. nerve condition studies D. physical therapy consultation Answer: Based on the chest radiography findings, the neonate in this vignette has a left humeral fracture likely sustained during birth. She is not moving her left arm because of pain, not neurologic injury. The next best step in management is immobilization of the left arm at 90 degrees. Long bone fractures involving the humerus and femur are not rare findings and occur more often with breech presentation. Additional risk factors and clinical features of humerus and femur fractures in the neonate are listed below. Fractures of the humerus heal quickly and rarely require additional therapy. They should be evaluated by a pediatric orthopedist on an outpatient basis.
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