CASE REPORT

Neonatology Division

RIGHT HUMERAL FRACTURE IN A NEONATE

BORN TO A SUSPECTED COVID-19 MOTHER

Rugayyah

Supervisor :
Dr. dr Ema Alasiry, Sp.A(K)
dr. A. Dwi Bahagia Febrianti, Ph.D, Sp.A(K)
Dr Amiruddin L, Sp.A(K)

Department of Child Health

Medical Faculty of Hasanuddin University, DR. Wahidin Sudirohusodo Hospital
Makassar 2020
INTRODUCTION
The rate fell
Maternal
from 2,6 to
1,9 per 1000 Factors

Birth
live births

Injury Neonatal
Caesarean Factors
Section

Significant
cause of
Neonatal
mortality Vaginal
and Delivery
morbidity
INTRODUCTION
First case In
Indonesian Child
Indonesia : announced on
9,3 % of all May 23rd rd 2020
cases

Covid-19
in children
Clinical
manifestation
varies depend on
the classification

Contribute
s to 2,1 %
of all death
cases
PATIENT’S IDENTITY

• Name : Mrs. SS’s Baby

• Gender : Male
• Date of birth : May 6th 2020
• Age : newly born
• Address : BTP, Makassar
• Admission date : May 6th 2020
• MR : 916171
PARENT’S IDENTITY
  Father Mother

Name Mr. K Mrs. SS

Age 40 years old 38 years old

Education Diploma Diploma

Occupation Ticket Clerk* House wife

*The parents live in Makassar, the father keep working during pandemi
while wearing a cloth mask.
CASE REPORT

The patient's social and personal history

Pregnancy Delivery Post Natal Nutrition Immunization
 35 years old  SC -> indication
of Breech  vitamin K  Formula milk via  The patient
 No routine ANC
 Do not suffer presentation. injection orogastric tube didn’t receive
from any certain  Baby aterm,
diseases didn’t  shortness of at day-1 any basic
 No History of immediately cry
breath after immunization
fever,  APGAR score 5/7
cough,sorethroat  Swelling of the delivery
, diarrhea. right arm were
 HT (-), DM (-), noticed  Mild subcostal
Asthma (-) simultaneously
retraction
 USG : Breech  BW 3010 g,
presentation length 49 cm,  No cyanosis.
 Chest XRay:Right head circum
pneumonia ference 33 cm  No seizures or
 Suspected covid- bleeding at birth
19
CASE REPORT
CASE REPORT
• Physical Examination (Objective)
Status present
General condition: Passive
Awareness: GCS 15 E4M6V5
Heart rate: 158 times / minute
Respiratory rate: 70 times/ minute
Temperature: 36.6 ° C
Pain scale: 1 NIPS
Head Mesosefal, normosefal. The crown was not
prominent
Hair Black, straight, not easily pulled. 
Face Symmetrical left and right, no dysmorphic
face.
Eyes There no hypertelorism. The conjunctiva
was not pale and there, non-jaundice
 
sclera, isochoric pupils, diameter ± 2 mm /
2 mm, light reflexes + / +.
normal impression
Nose No visible nasal lobe breathing, no visible
  secretions, no choana atresia.
Ear There were no secretions, no visible lowset
  ear.
Neck There was no webbed neck, no palpable enlargement of the cervical and
submandibular glands, no signs of meningeal excitement.
Chest Visible mild subcostal retraction. Symmetrical shape and movement. There was
  no pigeon chest.
Lung Bronchovesicular breath sounds, Additional noise in the form of rales, wheezing
  and grunting did not exist,
Heart Ictus cordis not visible, not touched by thrill. Pure I - II heart sounds, regular,
  no heart murmur.
Abdomen Flat in motion breathing, bowel sounds normal impression, liver and spleen are

not
. palpable. There are no ascites.
  Omphalocele and Gastroschizis were absent
CASE REPORT

Extremities . There was edema, bluish, crepitation, and lack of movement in the right arm.
  The grasp reflexes were normal. Babinsky primitive reflexes were positive,
no talipes
Skin There is no cyanosis, no jaundice
Lymphs gland There is no enlarged lymph nodes in the axilla or in the inguinal
Back no gibbus or scoliosis, no spina bifida
 
Genitalia Palpable both testicle in the scrotum 1x1 cm in size
 CASE REPORT Antropometric State

• Birth Weight : 3010 gram

• Body length : 49 cm
• Upper arm circumference : 12 cm
• Head circumference : 33 cm (normosefal according to the Lubchenco Curve)
• BW / A : Located between the 50th and 75th percentiles
• BL / A : Located between the 50th and 75th percentiles
• HC / A : Located between the 25th and 50th percentiled
• Intrauterine nutritional status: Aterm appropriate for gestational age
CASE REPORT

MATURATIONAL ASSESSMENT OF
GESTATIONAL AGE (New Ballard Score)

• Neuromuscular activity 20
• Physical maturity 15
• Total scoring 35
• Interpretation: 38-weeks of gestation
 Intrauterine growth status
CASE REPORT

Weight for age: between 50th and 75th percen Height for age: below 50th and 75th
tile based on the 38-weeks of gestation. percentile based on the 38-weeks of
CASE REPORT Intrauterine growth status

Conclusion:
• appropriate for gestational age
• Normal lenght
• Normoocephaly

HC for age: above 25th and 50th percentile

based on the 38-weeks of gestation.
CASE REPORT Laboratorium
Result

Parameter 05/01/2019 Normal value

(RS Wahidin)
HB 19.4 15-23,5 g/dl
MCV 101,6 80-100 µm3
MCH 34,7 27-32 pg
MCHC 34,7 32-36 gr/dl
HCT 56,8 37-47%
Leukocytes 22.120 4000-25.000 mm3
Erythrocytes 4.080.000 3.800.000-5.800.000/mm3
Platelets 241.000 150.000-400.000/mm3
CASE REPORT RADIOLOGY
RESULT

Baby gram Examination

(May 6th 2020) :
• Oblique fracture 1/3 distal
of right humerus.
• Lung, Heart and abdomen
within normal limit
CASE REPORT DIAGNOSIS

• Closed Fracture 1/3 distal of right humerus

• Baby of a suspected Covid-19 mother
• Aterm baby/ appropriate for gestational age
 
Planning

 PEEP 5 cmh20 and flow

8 liters / minute.
 Oxygen via nasal canule
1 liter/minute
Emergency management  Immobilization of the right
and medical treatment arm.
 Transfer the baby to the
neonatal intensive care unit
of infection centre (IC)

Plans for diagnostic • Routine blood tests

• Baby gram
support • Consult to the Orthopedic departement
PARENTAL EDUCATION
Explain to the parents that their baby has a birth
injury (humeral fracture) due to the Breech
presentation and will need special management for
the trauma.

The baby and the mother will be The baby will be consulted to
treated in the different negative orthopedic departement to
pressure room (IC), until the manage the humeral fracture.
PCR test revealed negative
Mrs SS baby, day-1 of treatment
 FOLLOW UP
Subjective: Passive
Objective : HR 144 bpm, rr 52 tpm, t 36.9 ° C, SpO2 99%. (No
Oxygen supplements)
No retraction, Icterus Kramer I, right arm was covered by long arm
back slab. Body weight 3040 grams
Lab: -
Assesment:
Closed fracture 1/3 distal of right humerus
Baby of a suspected covid-19 mother
Aterm newborn/ appropriate for gestational age
Planning:
• Fluid requirement 80 ml/kgbw /day
( Enteral = 8 x 30 ml of formula milk )via orogastric tube
• Collaboration with Orthopedic departement : observe the
longarm back slab
• Monitoring of the vital sign, respiratory effort, sign of
infection,icterus, feeding tolerance and deterioration.
• Waiting for the result of PCR test
May 7th 2020 (Day-2)
Subjective: Passive, yellowish skin
Objective : HR 138 bpm, rr 40 tpm, t 36.9 ° C, SpO2 98%. (No
Oxygen supplements)
No retraction, Icterus Kramer II, right arm was covered by longarm
back slab. Body weight 3030 grams.
Lab: -
Assesment:
Closed fracture 1/3 distal of right humerus
Baby of a suspected covid-19 mother
Aterm newborn/ appropriate for gestational age
Planning:
• Fluid requirement 100 ml/kgbw /day
( Enteral = 8 x 40 ml of formula milk )via orogastric tube
• Collaboration with Orthopedic departement : observe the
longarm back slab
• Monitoring of the vital sign, respiratory effort, sign of infection,
icterus, feeding tolerance and deterioration.
• Waiting for the result of PCR test
May 8th 2020 (Day-3)
Mrs SS baby, day-2 of treatment
FOLLOW UP
Subjective: Passive, yellowish skin
Objective : HR 138 bpm, rr 40 tpm, t 37,3 ° C, SpO2 98%. (No Discharged
Oxygen supplements)
No retraction, Icterus Kramer III, right arm was covered by longarm
back slab. Body weight 3030 grams. Wet umbilical cord stump
with purulent secretion.
Lab: PCR Swab test for the mother and baby were negative Parental education :
Assesment: • Immediately take the baby to emergency room if the
Closed fracture 1/3 distal of right humerus baby is fever, dyspnea, seizure, yellowish skin up to
Aterm newborn/ appropriate for gestational age the palm and soles.
Omphalitis • Advice the parents to control at the neonatal outward
Planning: clinic 3 days later.
• Fluid requirement 120 ml/kgbw /day • Place the baby under well-illuminated room.
( Enteral = 8 x 45 ml of formula milk )via orogastric tube • Routinly breast feeding as whenever the baby wishes.
• Collaboration with Orthopedic departement : conservative. or every 3 hours
Therapy according to peadiatric departement • Treat the fractured right arm : restrain arm motoric
• Umbilical cord stump care with alcohol swab/ 3 hours movement.
• Hepatitis B 0 and polio 0 immunization

May 9th 2020 (Day-5)

FOLLOW UP

• Quo ad vitam: dubia et bonam

• Quo ad sanationam: dubia et bonam
• Quo ad functionam: dubia et bonam
CASE ANALYSIS
Birth
Structural destruction or functional deterioration of the
Injury neonate’s body due to a traumatic event at birth

Birth injury : Accounts Humeral fracture :

for about 2 % of all approximately 0,2 per
deliveries. 1000 live births.

R
Maternal : obesity, cephalopelvic disproportion,
I small maternal stature, primiparity, prolonged
S
K labor
F
A
C Neonatal : extended operation duration,
T
O inadequate incision line, macrosomia, breech
r presentation, shoulder dystocia
 CASE ANALYSIS Birth Injury

In this case, the baby’s weight was normal, there was no

history of trauma and cesarean delivery was performed due
to the breech presentation. We considered that the fracture
was caused by the maneuvers performed during cesarean
delivery (particulartly during traction) due to the position of
the baby.
CASE ANALYSIS Birth Injury
Clinical
Manifestation
• Inability to move the affected ar • Lack of mobility.
m. • Crepitation
• Crepitus at the site of fracture
• Unequal arm diameter d
• Swelling and tenderness at the s
ue to hematoma-related e
ite of the fracture.
dema.
• Asymmetric Moro reflex
• Other fractures such as femur fr
• Asimetrical Moro reflex
acture, rib fractures can oc • Clavicle or femoral fracture
cur during birth but are rare. was not detected in the
• Can be associated with a X-ray examination.
brachial plexus injury • no paralysis signs.
Refferences This Case
CASE ANALYSIS Birth Injury
Diagnosis
Clinical Manifestation Clinical Manifestation
+ +
Radiology Finding Radiology Finding

Kumar SM, Chinese

Orthopaedic Association
2020

Refferences This Case

CASE ANALYSIS
Treatment
• In postnatal fractures,
remodelling is very rapid and
effective
• Humeral fracture rarely fails to
heal
• The established treatment
method is closed reduction
followed by cast immobilizati
on
Refferences
Birth Injury
• Immobilization was done using
a long arm back slab.
• The bone healing in neonatal
fracture start after 1-2 week
s.
• Based on the evaluation by
pediatric orthopedics, his rad
ial nerve functions were foun
d to be normal.
This Case
CASE ANALYSIS Birth Injury
Treatment

Casting of the right arm and Placement of long arm

Brown RD, placement of long arm splint back slab
Elsevier, 2017

Refferences This Case

CASE ANALYSIS Birth Injury
Prognosis

• Depends on the type and severity of
the initial injury.
• Hemorrages typically heal well
with occasional complications of
hyperbilirubinemia or infections.
• It can be accompanied by radial,
median or ulnar nerve injuries, or
combined arterial nerve injuries.
• Complete nerve paralysis is rare in
closed fractures in children and
nerve functions heal spontaneously.
• There were icterus kremer III in t
he day-3 of hospitalization.
• His radial and median nerve f
unctions were found to be normal.
• The longarm back slab was o
pened in the fifth day before dis
charged.
• The fracure was totally heal after 1
months

Refferences This Case

Mrs SS baby, 8 days of age, Neonatology outward clinic
CASE ANALYSIS
Prognosis

Mrs SS baby, 1 month of age

CASE ANALYSIS
Covid-19
Desember 2019 : outbreak of January 12, 2020 : WHO February 11 2020 : WHO
unexplained pneumonias in officially named this virus officially named this virus
Wuhan 2019-nCov Covid-19

May 23rd 2020: First case March 11 2020 : WHO

March 2nd
nd 2020 : First
of Covid-19 in Children in declared COVID-19 as
Case in Indonesia
Indonesia (Solo) a pandemic

June 1stst 2020: First case July 15thth 2020: First case
of Covid-19 in a 6 day old of Congenitally
baby in ndonesia (NTB) transmitted Covid-19
(France)
Flowsheet for the perinatal-neonatal management of suspected and confirmed covid-19 infection.

Wang, 2020. Chinese Expert

Concensus on the Perinatal and
Neonatal Management for the
Prevention and Control of the
2019 Novel Coronavirus Infection
Case Analysis
Covid-19
> Clinical Findings especially in premature infants are not spesific
> Temperature instability
> Respiratory & cardiovascular symptoms : tachypnea, grunting, nasal flaring, work of breath,
apnea, cough, tachycardia
> Other findings : poor feeding, lethargy, vomiting, diarrhea and abdominal distention

> Chest imaging is critical for the complete evaluation of covid-19 infection
> Pulmonary lesion are shown more clearly by chest CT scan : Ground glass opacity,
multiple bilateral lobular and segmental consolidations.
> Abdominal radiography : intestinal ileus

Laboratory Examination may be non spesific

> Normal leukocyte counts or decreased lymphocyte count
> Others : mild trombocytopenia and elevated levels of cretine kinase, alkaline phosphatase,
alanine aminotransferase, aspartate aminotransferase and lactate dehydrogenase
> Definitive test : Real time polymerase chain reaction (RT-PCR) from upper or lower respiratory
tract, blood or stool

Refferences
Case Analysis
Covid-19
> Clinical Findings in this baby were not spesific
> No Temperature instability
> No spesific Respiratory & cardiovascular symptoms
> No other findings

> Chest imaging : Lung, heart and abdomen were normal

> Laboratory Examination : within normal limit

> Definitive test : RT-PCR was negative

This Case
Case Analysis Covid-19
Delivery room Management

Venkat Reddy Kallem, Covid-19 in neonates,

The Journal of Maternal-Fetal & Neonatal Medicine
Case Analysis
Covid-19
Transport of The Neonate

Venkat Reddy Kallem, Covid-19 in neonates,

The Journal of Maternal-Fetal & Neonatal Medicine
Case Analysis
Covid-19
Postnatal management of a stable Postnatal management of a stable
neonate born to a suspected COVID neonate born to a confirmed COVID
mother mother with facilities for separate
isolation not available

Venkat Reddy Kallem, Covid-19 in neonates, The Journal of Maternal-Fetal & Neonatal Medicine
 Case Analysis Covid-19
Post natal management of a stable neonate
born to a confirmed COVID mother with facilities for

separation isolation available

Venkat Reddy Kallem, Covid-19 in neonates,

The Journal of Maternal-Fetal & Neonatal Medicine
 Case Analysis Covid-19
Postnatal management of a sick neonate born to a suspected/confirmed COVID mother

Venkat Reddy Kallem, Covid-19 in neonates,

The Journal of Maternal-Fetal & Neonatal Medicine
Case Analysis
Covid-19
Asymptomatic infection :
 Nasopharyngeal swab should be collected and tested every 2
days (with at least 24 hours interval) until 2 consecutive result
show negative

Discharge Mild Infection :

Criteria  Normal temperature for more than 3 days
 Improved symptoms
 Negative swab test for 2 consecutive times (24-h interval)

In this case, the baby showed
no symptom, he was discharged
after 5 days of hospitalization
after 1 consecitive result show
negative
Severe Infection :
 Normal temperature for more than 3 days
 Improved symptoms
 Pulmonary imaging should show inflammation disappearing.
 Negative swab test for 2 consecutive times (24-h interval)

Wang Et Al, Chinese Expert Concensus on the Perinatal and Neonatal Management for the Prevention
and Control of the 2019 Novel Coronavirus Infection,
Conclusion
• A case of a male newborn with a birth injury, born to a covid 19
suspected mother has been reported.
• The diagnosis of birth injury is based on clinical examination, and
supported by radiological examination.
• The patient confirmed negative for covid-19 (RT-PCR was negativ
e)
• The patient had a good prognosis.