Sirs,

Femur fracture is an important birth injury. While vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause it, and only a few reports have described it [1–7]. Here, we report a newborn suffering a femur fracture during abdominal breech delivery. This case increases the awareness of this problem.

A 2,490-g female infant was delivered at 38 1/7 weeks of gestation by elective cesarean section for breech presentation in a 37-year-old, primiparous woman. She had no history of previous uterine surgery. Combined spinal and epidural anesthesia was performed with adequate analgesia and muscle relaxation. An incision was made in the lower segment as usual, and the infant’s buttocks and iliac crest lay beneath the incision site. The infant was in a frank breech presentation. Extraction was attempted by locking the index finger in the groin on both sides and exerting traction as usual. We did not use the Pinard maneuver; we did not pull out the thigh. Although traction was a little difficult, possibly due to a tight uterine incision, the buttocks and lower extremities were pulled out without employing further maneuvers, with the thighs being pressed against the fetal abdomen. Just at the moment of delivering the buttocks and the thighs from the incision, a “crack” was heard, which a nurse recalled later. A female infant weighing 2,490 g with 1- and 5-min Apgar score of nine and nine, respectively, was delivered. Routine examination soon after delivery revealed no abnormalities. We did not pay special attention to the thigh at that time. The next day, the right thigh showed slight swelling with decreased mobility compared to the left. These signs, together with the suggestion from a nurse recalling the “crack”, led us to perform a radiographic examination, which revealed a fracture in the femur shaft with the proximal portion displaced anteriorly (Fig. 1a). Bone structure and bone mineralization appeared normal. We found no other bone fractures/deformities or blue sclera, signs for osteogenesis imperfecta. We also found no hypotonia, a sign for Weldnig-Hofmann disease, which was reported to induce disused atrophy of the bones and thus pathological long bone fracture in newborns [8]. A simple splinting was applied. Radiograph on day 13 after birth revealed callus formation at the fracture site (Fig. 1b). On day 20, the callus appeared more evident (Fig. 1c) and the cast was removed. On day 23, she actively moved her right leg and was discharged. On day 75, the fracture almost completely healed (Fig. 1d). At 20 weeks after birth, at the time of writing, the legs showed an appropriate range of movement without length discrepancy.

Fig. 1
figure 1

X-rays of right femur of the newborn. Right femur shaft is fractured, with the proximal portion displaced anteriorly (a, day 1 after birth). Callus, although weak, can be observed at the fracture site (b, day 13), becoming more evident (c, day 20), and finally healing of the fracture is observed (d, day 75)

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Only five English language reports, to our knowledge, have provided data regarding six singleton newborns with femur shaft fracture during abdominal breech delivery; we added one more. This case suggested two important clinical issues.

First, we must be aware of the possibility, though quite low, of femur fracture during breech abdominal delivery. A randomized multicenter trial by Hannah et al. [9] indicated that long born fracture occurred in 0.1% (1/1041) and 0.5% (5/1042) from abdominal and vaginal breech deliveries, respectively; planned cesarean section reduced the risk of long bone fracture, but it may not reduce femur fracture to zero. Table 1 summarizes the clinical features of seven singleton cases of femur shaft fracture during abdominal breech delivery. Difficult extraction, and thus femur fracture, has been considered to be induced by several factors; heavy infant weight [1, 2], twin pregnancy [6], the presence of myoma [1], and inadequate uterine relaxation [5], although its reason was not specified in the present case. Heavy weight does not appear to be a culprit; all seven injuries occurred in newborns of average weight (median 3,220 g, range 2,490–3,700 g). Four cases had a difficult extraction; one due to an impacted foot in the pelvis (Case 3 [5]), and another due to previous uterine surgery leading to a tight uterine incision (Case 4 [5]). Three women were in labor and underwent emergency cesarean section (Case 1 [3], 3 [5], and 4 [5]); the breech-presenting part may be well engaged in the pelvis, and thus strong extraction may be needed. A scarcity of data prohibits us from proposing a suitable maneuver to avoid femur fracture. However, taking all data [1–7] into consideration, adequate analgesia, gentle traction, and a uterine incision large enough for easy extraction may be important to avoid the injury. If more space is needed, we should not hesitate to incise more instead of continuing with a difficult traction. In the present case, although we are unable to specify the reason for the injury, we actually had slight difficulty in the traction; thus, we should have incised more at that time. All six infants, including this patient, showed complete healing without sequelae only with a cast or a splint.

Table 1 Clinical features of cases with femur fracture during abdominal breech delivery
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Second, a “crack” may be an important clinical sign for the early detection of femur fracture, which was observed in four cases, including the present case. Different from the expectations, some cases (Cases 5 [6] and the present case) did not show marked swelling at the site on the day of delivery. We employed an ordinary maneuver except for having had a little difficulty in extraction, and thus we did not at first suspect a femur fracture; however, one nurse recalled the “crack”, recommending us to perform a radiological examination, and revealing the fracture the day after birth. This agrees well with previous observations by Morris et al. [6]; no evidence of a femoral injury was noted on the immediate postnatal examination, and a mean of 6.3 days (range 1–21) was required for diagnosis. It may be important for the early detection of femur fracture to pay attention to a “crack”.

We must admit that in the present case, although we employed ordinary procedure for breech abdominal delivery, we should have incised the uterus more, and should have paid more attention to the “crack” during the surgery. Femur shaft fracture can occur in abdominal breech delivery. Recently, femur epiphyseal [10] or metaphyseal [11] fractures were also reported to occur in infants delivered by elective cesarean section for breech presentation. Clinicians must be aware that abdominal delivery does not preclude the occurrence of femur fracture.