J Ultrasound Med 4:467- 470, September 1985

Clavicular Measurement:
A New Biometric Parameter for Fetal Evaluation
Shaul Yarkoni, MD, Werner Schmidt. MD, Philippe Jeanty, MD,
E. Albert Reece, MD, John C. Hobbins, MD

Fetal clavicular length was measured sonographically in 85 fetuses with ges-

tational ages ranging from 15 to 40 weeks. Biparietal diameter (BPD) and
femur length (FL) were also measured. A linear correlation was found be-
tween clavicular length and gestational age (coefficient of correlation = 0.81).
A simple relation was found: The gestational age in weeks is approximately
equal to the length of the clavicle as expressed in millimeters. The mea-
surement of clavicular length can be a useful parameter for the estimation
of gestational age and in the detection of congenital anomalies that affect the
clavicles. Clavicular measurements may also prove useful in the detection of
macrosomic fetuses at high risk for obstructed labor or shoulder dystocia.
(Key words: clavicle , fetal; congenital anomalies ; shoulder dystocia)

Fetal visualization by ultrasonography enables us
to follow fetal growth from early gestation to term.
In recent vears fetal biometrv has included head,
body, and iong hone measure;nents. 1- 3 These mea-
surements allow us to evaluate normal and patho-
logic states of fetal growth during pregnancy.~ A
major advantage of fetal biometry using ultrasonog-
raphy is the prenatal diagnosis of various congenital
anomalies. 3 Although the growth of many fetal
bones has been studied by several investigators,
clavicular measurements across gestational age
have not been previously reported. Measurement
of the clavicle is of special interest since it permits
not only the estimation of gestational age, but also
the detection of severe congenital anomalies such
as cleidocranial dysplasia, Holt-Oram syndrome,
Goltz syndrome., Melnick-Needles syndrome, and
others. 6 - 13
The purpose of this report is to establish normal
data for fetal clavicular development during preg-
nancy.
.MATERIAL AND .METHODS
The study group consisted of 85 patients with
normal pregnancies who were referred for routine
Received January 15, 1985, from the Division ol Maternal-Fetal
Medicine of the Department of Obstetrics and Gynecology, Yale
University School of Medicine, New Haven, Connecticut Accepted
lor publication March 13, 1985
Address correspondence and reprint requests to Or. YarkonL De·
partment of Obstetrics and Gynecology, Yale University School of
Medicine, 333 Cedar Street, P.O. Box 333, New Haven, CT 06510·
8063.
ultrasound examination. Only patients whose bi·
parietal diameter {BPD) and femur length con-
firmed dates were included in this studv.
The gestational ages ranged frmn 15 t~ 40 weeks.
The ultrasound examinations were performed using
commercially available real- time equipment
(Technicare 256 S. 3.5 MHz; Toshiba SAL 50A. 5
M Hz). The measurements were obtained by two
observers (SY, WS) with the electronic calipers of
the equipment. To obtain the maximal length of
both clavicles, serial transverse scans of the upper
fetal chest were done (figs. 1 and 2}.
Only one measurement for each patient was re-
corded to provide cross-sectional analysis. The data
were then stored and analyzed using an IBM PC
with Lotus 123® (Lotus Development Corp. , C••m-
bridge. MA), Pairstats' (Davell Custom Software,
Cleveland, TN), and WordStar (Micropro Corp. ,
San Raphael, CA). Polynomial regressions were
routinely obtained to the third order, and the equa-
tion providing the highest coefficient of multiple
correlation and smallest standard deviation W"clS se~
lected. Correlations of clavicular length (CL) to
gestational age (GA), to biparietal diameter {BPD),
and to femur length (FL) were established . For
each correlation, the regression and standard de·
viation were calculated.
RESULTS
The growth of the fetal clavicle during pregnancy
was found to be linear (fig. 3). A linear correlation
was also observed between clavicular growth,
467
 Figure 1 (left). Clav ~
id es at 15 weeks' ges~
tational age. CL, clavi·
c le; s. spine.
Figure 2 (right). C l avi~
c les at 32 weeks' gesta·
tional age. C , clavicle;
S, spine).

•5 42
•o . /

40 3~ ~ ·
36
35 34
32

e
30
30 i
.
28
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.
..... 26
25 ~
u .!!: 2; ~
>0
u 20 ...
.!! 22
20
18
15 16
I <I
10
10
5 8
12 36 20 40 60 80 100
G••totlonal a g e ( we ek s.) S lpDrleiDI diDmet• • (mm)

•2 40
•o 38
38 36
3~
34
3.
....
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32 M
32
30 ""'• 30
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.
28 28
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Fe mu• (mm } C!Dvlcie (mm)

Figure 3 (upper left). Clavicular length versus gestational age with 5th, mean, and 95th percentile.
Figure 4 (upper right). Clavicular length versus blparjetal diameter with 5th, mean, and 95th percentile.
Figure 5 (lower left). Clavicular length versus emur rength with 5th. mean, and 95th percentile.
Figure 6 (lower right). Gestational age versus clavicular length with 5th, mean, and 95th percentile.
 FETAL CLAVICULAR MEASUREMENTS- VOLUME 4, SEPTEMBER 1985 469

Table 1. Polynomial Regressions • Table 4. Gestational Age as Obtained from

Clavicle Length
CL = 1.118303 + 0.9788639 GA
CL = 6.441404 + 0.3187418 BPD Gestational Age
CL = 9.304238 + 0.3788338 FL Clavicle
(weeks and days)
GA = 3.717731 + 0.8272778 CL Length
Percentile
(mm) 5th 50th 95th
* Bone lengths and BPD expressed in mm: age expressed
in weeks. 11 8 +3 13 + 6 17 +2
CL, clavicular length; GA, gestational age; BPD, biparietal 12 9 +1 14 + 4 18 +1
diameter; FL, femur length. 13 10 +0 14 + 3 19 +6
14 11 + 6 15 + 2 20 + 5
15 12 + 5 16 + 1 21 + 4
Table 2. Coefficients of Correlation (r2) and Standard 16 12 + 3 18 + 0 21 + 3
Deviations (SO) 17 13 + 2 18 + 5 22 + 2
18 14 + 1 19 + 4 23 + 0
r2 SD 19 16 + 0 19 + 3 24 + 6
CL from GA 0.807 2.920 20 16 + 6 20 + 2 25 +5
CL from BPD 0.792 3.029 21 17 + 4 21 + 1 26 +4
CL from FL 0.805 2.936 22 17 + 3 22 + 6 26 + 2
GA from Cl 0.807 2.684 23 18 + 2 23 + 5 27 + 1
CL, clavicular length; GA, gestational age; BPO, biparietal
24 19 + 1 24 + 4 28 + 0
diameter: FL, femur length.
25 21 + 0 24 + 3 29 + 6
26 21 + 5 25 + 1 30 + 5
27 22 + 4 26 + 0 30 + 3
28 22 + 3 27 + 6 31 +2
Table 3. Clavicle Length as Obtained from 29 23 + 2 28 + 5 32 + 1
Gestational Age 30 24 + 0 29 + 4 34 + 0
Clavicle Length (mm) 31 25 + 6 29 + 2 34 + 6
Gestational Percentile 32 26 + 5 30 + 1 35 + 4
Age 33 27 + 4 31 +0 35 + 3
(weeks) 5th 50th 95th 34 27 + 3 32 +6 36 + 2
15 11 16 21 35 28 + 1 33 +5 37 + 1
16 12 17 22 36 29 + 0 33 + 3 39 + 0
17 13 18 23 37 30 + 6 34 + 2 39 + 5
18 14 19 24 38 31 + 5 35 + 1 40 + 4
19 15 20 25 39 32 + 4 37 + 0 40 + 3
20 16 21 26 40 32 + 2 37 6+ 41 + 2
21 17 22 27 41 33 + 1 38 4+ 42 + 0
22 18 23 28 42 35 + 0 38 3+ 43 + 6
23 19 24 29 43 35 + 6 39 2+ 44 + 5
24 20 25 30 44 36 + 5 40 + 1 45 + 4
25 21 26 31 45 36 + 3 41 + 6 45 + 3
26 22 27 32
27 23 28 33 BPD, and femur length (figs. 4 and 5). Thus, ges-
28 24 29 34 tationul. age can he estimated using clavicular
29 25 30 35 length {see table 4). The polynomial regressions of
30 26 31 36 all parameters are listed in table 1 and the coefll-
31 27 32 37 cients of determination (r2) in table 2. The davie-
32 28 33 38 ular length during pregnancy with the 5th, the
33 29 34 39 mean. and the 95th percentile is given in table 3.
34 30 35 40 The estimated gestational age with the 5th, the
35 31 36 41 mean. and 95th percentile as derived from the cia-
36 32 37 42 vicular length measurement is presented in ta-
37 33 38 43 ble 4.
38 34 39 44 A simple relation for the estimation of gestational
39 35 40 45 age was established. The estimated gestational age
40 36 41 46 in weeks is roughly equal to the length of the cia-
vide expressed in millimeters.
470 YAAKONI ET AL- JOURNAL OF ULTRASOUND IN MEDICINE
DISCUSSION
The clavicle is one of the fetal hones demon-
strating a linear growth pattern during intrauterine
life. Therefore, fetal clavicular length measurement
can be used as an additional parameter for esti-
mation of gestational age. An ussay formula links
both variables: the estimated gestational age in
weeks is approximately equal to the clavicular
length in millimeters.
The clavicle is an important bone of the shoulder
girdle. In difl"erent congenital anomalies involving
this part of the fetal hod y the clavicle may he af~
fected. The most significant <.·ongc nital anomaly
with au associated defect of the clavicle is the Holt-
Omm svndrome, whieh ineludes dcleets or short~
ening o.f the elm ieular length , md. defects of the
shoulder girdle, the limhs , ami the cardiovascular
sys tem /; Other r: ongenilal syndromes in whieh the
clavicle ean he allcetcd ar ~ cleidoeranial dysplasia
with aplasia of th e clavicle. hrach ycephaly. and
bossing ot' the cranium;j and Goltz syndrome, with
hypoplasia or aplasia of the elavicle, skin anomalies.
d ys trophic nails, hypoplasia of the teeth, syndac-
tyly of fingers or toes, and occasionally other skel-
etal delormities.H In Mdnick-Needles svndrome,
the skeletal s\•stc m is afleeted to a laq,ie extent,
including shorte ning of the elavielcs. a small tho·
racic cage with irregular ribbon-like rihs, s hort-
ening of the uppe r arm , bowin~ of the radius and
tibia, and small f~tcial hones with prominent eyes. !J
Other syndromes that might affect the clavicle in-
clude heart-hand svndrome with secundum atrial
septal defect and ttpper limh phocomelia. which
may he associated with anomalies of the clavicle.
Progeria is usually associated with shortened and
thin clavicles. 10 In pyknodysos tosis. the clavicles
are dysplastic with partial aplasia of the acromial
ends. 11 Sprengel deformity .shows elevated sca-
pulae with clavicular, spinal. <tnd <.·ostal defi:mni-
ties. 12 Auriculo· osteodysplusiu includes anomalies
of the clavicles and the scapu1ne. 13
Clavicular length predominantly dete rmines the
shoulder width. It is well known that in macro-
somic fetuses the shoulder width exceeds fetal head
dimensions. This fact can cause seve re and even
fi1tal shoulder dystocia during delivery. Therefore.
fetal clavicular length. e specially in diabetic preg-
nancies, may be a reliable parameter for predicting
the risk of shoulder dystocia. This hypothesis is
now being tested by our group,
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