Obstetric fracture of the femur during cesarean section in a preterm baby: A case report

Introduction: Obstetric fractures or Birth fractures are rare events following childbirth. Although fracture of the femur is a relatively uncommon injury, it is the most common fracture of the lower extremity in the newborn. Since evolution of cesarean section rates in Africa, it is one of the most commonly practiced modes of delivery for breech. We described one case of fracture of the femur at cesarean section treated at Adlucem hospital in bonabéri-Douala (Cameroon). Case report: A 2.1 kg male infant was delivered by lower segment cesarean section for breech presentation. Clinical and radiological examination showed shaft fracture of femur with good evolution. Discussion: Fractures of the long bones are associated with cesarean section, breech delivery with assistance and low birth weight. Femoral fractures are the most associated long bones fracture with cesarean section. Conclusion : The clinical and paraclinical diagnosis is simple and the management is mostly non-operative. It is important to explain to the parents and especially to the mother the benignity of the lesion.


Introduction
Obstetric fractures or Birth fractures are rare events following childbirth 1 . They can occur during vaginal or cesarean delivery 1 . Birth fractures almost always involve the clavicle, humerus, and femur 2 . Although fracture of the femur is a relatively uncommon injury, it is the most common fracture of the lower extremity in the newborn 2,3 . The majority of neonatal femoral fractures occur following vaginal breech delivery [nadas]. Since evolution of cesarean section rates in Africa, it is one of the most commonly practiced modes of delivery for breech 4 . One tends to think that birth femur fracture does not occur in these babies who are delivered by cesarean section. We therefore present this case and six other similar, previously reported cases to increase the awareness of this problem. It is also possible that many other cases may not have been reported in the literature 2 . We described one case of fracture of the femur at cesarean section treated at Adlucem hospital in bonabéri-Douala (Cameroon).

Case Report
A 26-year-old nondiabetic multigravida (Pregnancy 3 and childbirth 3) mother who was treated with quinine in the third trimester of pregnancy for Malaria. At the gestational age of 34 weeks, she had uterine contraction with signs of acute fetal distress. A 2.1 kg female infant was delivered by lower segment cesarean section for breech presentation. During cesarean section the obstetrician encountered difficulty in delivering the baby due to the engagement of foetal breech. The baby cried immediately at birth. Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. On the 1st day the examination revealed swelling in the left mid-thigh region and a click in the left femur. The left leg's mobility was very decreased compared with the right. The rest of the examination was unremarkable. Radiographic examination The X-ray of the left thigh revealed a femur fracture type 32-D/5.1 AO Pediatric Comprehensive Classification of Long-bone Fracture (PCCF) (Figure 1). After two days of stuck traction, hip spica cast (extends from the torso down to the foot) was applied, and the baby was discharged home. A follow-up radiograph at three weeks showed callus formation at the site of fracture and also a periosteal reaction at the site of fracture ( Figure 2). A follow-up radiograph at 9 months showed good healing and the baby was doing well clinically. The neonatal course and 9-month follow-up with good recovery does not support the possibility of pathologic fracture, and no attempts were made to investigate further the cause of the fracture.

Discussion
Obstetrical fracture can be divided into three (3) groups: depressed fractures of the skull, fractures of long bones and fractures of the clavicle 5 . There are many predisposing factors associated with these groups of obstetrical fractures 5 . Depressed skull fractures are associated with manoeuvres and the use of forceps during delivery 5 . Obstetrical fractures of long bones are rare. The reported incidence ranges from 0.028% to 0.054% 5 . Fractures of the long bones are associated with cesarean section, breech delivery with assistance and low birth weight 5,6,7 . Femoral fractures are the most associated long bones fracture with cesarean section 5 .

Long bone fractures do not pose diagnostic difficulties.
A cracking sound can be heard in the delivery room. Deformation of the diaphyseal bone segment, pain during movement or a pseudo-paralytic attitude can be observed 3 . These fractures occur both in newborns of primiparous and multiparous mothers 3 . No study mentions prematurity in newborns like our case, but more the low birth weight 5,6,7 or large babies with difficult delivery at cesarean section 8,9 . The paraclinical diagnosis makes it possible to make a diaphyseal or metaphyseal localization. In our case, the diagnosis of mid-diaphyseal fracture was made thanks to an X-ray, given the poverty of the family. According to Deschênes et al. standard radiography should be avoided whenever possible; ultrasound is the diagnostic tool of choice, completing the clinical examination before the age of 03 months 3 . It is important to explain to the parents and especially to the mother the benignity of the clinical and paraclinical lesion.
Diaphyseal femoral fractures are treated with cast immobilization without the need for precise alignment of bone fragments 5,6,7 . Newborns benefit from the extraordinary potential for skeletal remodeling at this age. Bonded traction can be used for femoral fractures 1 . It was used in our patient. There is no indication for surgical treatment [1][2][3][4][5][6][7][8][9][10] . Consolidation is constant and very quickly obtained [1][2][3][4][5][6][7][8][9][10] . In the event of a very unstable epiphyseal detachment fracture, surgical treatment by osteosynthesis may be necessary. Regular monitoring of the child until the end of growth is necessary. Complications included infection, malunion, nonunion are very rare. We have not found any in the literature. Bistoletti et al. reported 9.2% incidence of traumatic morbidity in infants delivered vaginally, but no incidence of traumatic morbidity in infants delivered by cesarean section 10 . Cesarean section does not reduce the traumatic morbidity in average-sized infants to zero 2 .

Conclusion
Femoral fractures at abdominal delivery are rare events. Most fractures occur in low birth weight and large babies with difficult delivery at cesarean section. The clinical and paraclinical diagnosis is simple and the management is mostly non-operative. It is important to explain to the parents and especially to the mother the benignity of the lesion.

Declaration of Competing Interest
None