**2. Clavicle fractures**

Fractures of the clavicle are the most common neonatal fractures. They are usually found in vaginal delivery of an overweight neonate. Shoulder dystocia is a severe complication during birth and immediate action is required from the obstetrician in order to avoid respiratory disturbance of the neonate. The fracture of the clavicle reduces the shoulder tension and promotes the early delivery of the neonate. Otherwise the hyperextension of the neck may lead to severe brachial plexus palsy. A fracture of the clavicle in a neonate can be diagnosed without history of dystocia, most commonly after a cesarean delivery. Urgent cesarean births have a higher incidence of clavicle fractures. Delayed deliveries over 39 weeks of gestation are reported with a higher incidence of clavicle fracture and brachial plexus palsy [8–14].

The main clinical sign is the restricted Moro reaction sign (Moro (startle) reflex, arms abduct in response to sensation of falling) that is the reduced abduction and external rotation of the affected arm. This is the most common examination test that the neonatologist performs in the newborn. The newborn has active movements of the wrist and fingers and easy flexion of the elbow in the affected side. The newborn expresses discomfort and is crying while changing clothes or while moving the arm while breast feeding. Oedema in the clavicle region appears usually in the 2nd and 3rd day, with crepitus while examining the clavicle. The clavicle ossifies following intramembranous and not endochondral ossification. It produces early an enlarged callus that is remodeled and the signs of the clavicle fracture are eliminated by the 3d month. Clinical signs are often obscure early and the family notices the presence of the enlarged callus in the clavicle region after a week time. There are normal movements of the affected side and even the Moro sign may have been reported as normal.

Radiological examination confirms the diagnosis and is mainly performed for the medico legal issues in case that there are associated lesions as brachial plexus palsy. Radiological examination is not always required since in typical cases we can reassure the parents for the benign course of the clavicle fracture. Ultrasound examination from an experienced radiologist can assist by confirming the disruption of the cortical continuity. There is no specific treatment that is required for this fracture. We inform the nurses and the family for the appropriate dressing and bathing of the neonate and to avoid the elevation of the affected arm. In a few days the neonate is moving the arm without discomfort. The arm is kept in the relaxed position with the elbow in 90 degrees of flexion, in the anterior part of the body (**Figures 1** and **2**).

The presence of an enlarged lump on the right clavicle of a baby, after several months, must be differentiated from congenital clavicle pseudoarthrosis. This is an extremely rare dysplasia, usually diagnosed in the preschool age, as it is a painless lump in the clavicle. Appropriate imaging with X-ray and CT scan confirms the diagnosis of the congenital pseudoarthrosis. There is absence of history of birth trauma. This dysplasia can be treated surgically with appropriate excision and plating, mainly for esthetic reasons. A new born with bilateral pseudoarthrosis of the clavicle that presented spontaneous recovery has been reported [15, 16] (**Figures 3** and **4**).

**Figure 1.** *Fracture of left clavicle.*

**Figure 2.** *Unable to perform the Moro reaction with the left arm.*

**Figure 3.** *X-ray-s of bilateral clavicle pseudoarthrosis with spontaneous union at a year time.*
