Seymour Fracture Research Articles

Complication Rates in Patients With Classic and Radiographic Variants of Seymour Fractures.

At a tertiary-care, level 1 pediatric trauma center, we have observed fractures of the distal phalanx involving the physis, with associated nail bed injuries, that are distinct from the classic description of the Seymour fracture. We investigated the time to definitive management and the associated morbidity of these Seymour fracture variants compared with classically described Seymour fractures. We hypothesize that these Seymour variants are similarly problematic in terms of complications and delays to the definitive treatment and thus warrant increased awareness. A retrospective chart review was performed of all patients with distal phalanx fractures involving the physis and associated nail bed injuries that were treated with operative intervention at a single pediatric specialty institution over a 9-year period. Radiographs and clinical photographs were reviewed to determine if the patient presented with a classic Seymour fracture or variant. Primary outcomes included time from injury to definitive treatment and complication rate. Of the 66 Seymour fractures identified in the chart review, 36 (55%) were identified as classic Seymour fractures and 30 (45%) were identified as variants. The mean time to operative intervention in the classic and variant groups was 7.3 versus 12.7 days (P=0.216). The complication rates in the classic and variant groups were 11.1% versus 23.3% (P=0.185), with infections accounting for nearly all complications identified. Overall infection rates for the classic and variant cohorts were 8.3% and 20.0% (P=0.169), respectively, with the majority presenting preoperatively (5.6% vs. 13.3%, P=0.274). We found that patients with classic Seymour fractures or radiographic variants had statistically similar incidence rates, complication rates, and delays in treatment, with a trend towards higher complication rates and delayed time to treatment in patients with variant-type injuries. We propose a minor expansion of the definition of Seymour fractures to include common variants to increase awareness of these problematic injuries, minimize delays in treatment, and decrease complications. Level III; Retrospective Comparative Study.

Does K-wire fixation improve outcomes in children with a Seymour fracture?

IntroductionThe Seymour fracture is a juxta-epiphyseal fracture of the terminal phalanx of the finger. Sources vary on the recommended management, with some advocating treatment without K-wires to avoid metalwork-associated infection, and others suggesting that K-wire fixation is necessary due to the risks of fracture re-displacement. MethodsA best evidence topic in paediatric hand surgery was written according to a structured protocol. Searches were performed on December 28, 2021 in Cochrane library and PubMed. Results69 papers were found using the reported search strategy, and eight papers representing the best evidence to answer this question are discussed. DiscussionThe evidence on this subject is suboptimal as five of these studies were case-series that do not make direct comparisons between the question's intervention and control groups, and the other three were single-centre retrospective cohort studies with no randomisation. ConclusionThe best evidence topic concludes that K-wire fixation appears to be associated with a higher rate of physeal disturbance and lower rates of infection, fracture re-displacement, and flexion deformity.

Bipartite nail deformity due to seymour's fracture in a pediatric patient

Seymour fractures occur in the form of juxta-epiphyseal fractures in the distal phalanx bone of children, which are often accompanied by nail bed injuries. These fractures are also associated with complications such as nail deformity, infection, and growth disturbance. This report introduces a 6-year-old boy whose Seymour fracture occurred with the interposition of the nail bed on the fracture site, resulting in nonunion and nail deformity in the form of bipartite growth. Nail bed injuries could be accompanied by Seymour fractures and their treatment is independent of the fracture treatment. Nail bed repair can prevent subsequent deformities.

Seymour fracture: Better do not underestimate it.

Objectives This study aims to analyze the functional results, management, and complications of acute Seymour fracture treatment and to generalize the understanding of Seymour fractures, as well as awareness about its controversial treatment and critical sequelae.Patients and methods Between January 1994 and December 2019, a total of 29 patients (20 males, 9 females; mean age: 7.9±3.9 years; range, 1 to 15 years) who presented within the first 24 h of injury and were diagnosed with Seymour fractures and treated in the emergency setting were retrospectively analyzed. Clinical and radiological data were collected from medical records at the time of diagnosis and during follow-up, within a week after the treatment and in the visits required until fracture healing, and no sequelae were observed. In the event of complications, a minimum of one year of follow-up was carried out. Radiographs were taken of the anteroposterior and lateral views during each visit.Results The mean follow-up was 10.8±8.6 (range, 2 to 36) months. Surgical treatment in the operating room was performed in 24 (82.7%) patients using a single longitudinal Kirschner wire (K-wire) fixation through the distal phalanx and the distal interphalangeal joint in 21 patients. Non-operative treatment based on closed reduction and splinting was performed in five (17.3%) patients. There was no statistically significant difference in the final passive range of motion and physeal growth arrest in relation to the use or non-use of K-wires. The use of antibiotics in any of the three possible administrations (intravenous antibiotic regimen, intravenous and later oral antibiotic at-home or oral antibiotics), in relation to the non-use of antibiotics seemed to be a protective factor against infections (odds ratio=0.04; 95% confidence interval: 0.006-0.2; p=0.001).Conclusion The identification of Seymour fractures is crucial for applying the correct treatment and reducing the risk of complications, such as osteomyelitis and physeal alterations. Based on our study results, we can suggest that the use of an antibiotic regimen causes a lower risk of infections in acute Seymour fractures. The prompt identification of these fractures with a standardized protocol covering irrigation, debridement, reduction, fixation, and prophylactic antibiotics is needed to avoid complications.

1070 A Systematic Review of Seymour Fracture Management

Abstract Aim Seymour fractures are distal phalanx fractures of the finger in children with a juxta-epiphyseal or Salter-Harris Type I/II pattern associated with a nail-bed injury. There remains a paucity in literature regarding the development of complications between Seymour fracture management options, with early studies encouraging non-operative management due to the increased rates of post-operative infection. This systematic review aims to identify present-day, optimal management strategies for Seymour fractures, with further analysis of infection rates and secondary outcomes during post-operative recovery. Method Free-text search, MeSH terms and expanded keywords/phrases were employed to search the PubMed, Embase (via Ovid), Web of Science and CINAHL databases. Studies that described the management of Seymour fractures in paediatric patients were included, subject to inclusion/exclusion criteria. The data extracted included the sample size, intervention, infection rates and secondary outcomes. Results An initial search identified 305 articles, following the PRISMA guidance, 8 studies were eligible for full-text analysis. Across all studies, 307 Seymour fractures were identified (mean age, 10±1.2 years). A cross-study analysis showed a lower rate of adverse outcomes (including malunion/non-union and unplanned operative intervention) for K-wire fixation when compared to external splinting, 8.3% and 20.7% (P ≤ 0.001), respectively. Conclusions There was no statistically significant difference between non-operative and operative management in rates of infection and adverse outcomes. However, further analysis revealed a significantly lower risk of complications in patients who received K-wire fixation when compared to external splinting. Nonetheless, further studies with greater levels of evidence need to be carried out to consolidate this.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. Level IV-retrospective case series.

Diagnosis and Management of Common Pediatric Fingertip Trauma

Fingertip trauma commonly presents to pediatric emergency departments. Most injuries can be managed at the bedside with anesthesia, irrigation, soft tissue repair, immobilization, and follow-up. A comprehensive team approach allows for a nurse practitioner as the first point of contact with involvement of a hand surgeon and hand therapist as necessary to provide optimal care. This topical review provides an anatomical framework to assist first-line providers in the appropriate diagnosis and management of common pediatric fingertip injuries as well as identify and rule out conditions that warrant time-sensitive surgical intervention such as Seymour fracture, tendon laceration/avulsion, or dysvascular digit.

P087: A comparison of how emergency physicians and plastic surgeons evaluate and triage pediatric hand fractures: a prospective trial of the Calgary Kids’ Hand Rule

Introduction: Hand fractures in children are common and most are adequately managed with immobilization alone. There is a subset of fractures that require surgery as well as a fear of growth plate disturbance. For these reasons, triaging the so-called “complex” fractures that require specialized care by a hand surgeon is critical. In an effort to improve triaging for pediatric hand fractures, we previously derived and internally validated a prediction model for pediatric hand fracture triage using multivariable logistic regression with bootstrapping. The primary outcome was “complex fracture”, a definition we assigned to any fractures that required surgery, closed reduction or more than four appointments with a plastic surgeon. The model identified six significant predictors of complex fractures: angulation, condylar involvement, dislocation or subluxation, displacement, open fracture, and malrotation with strong performance (C-statistic 0.88) and was named the Calgary Kids’ Hand Rule (CKHR). Methods: A prospective cohort study was conducted at the Alberta Children's Hospital from April 1 until December 31, 2019. Eligible patients included children 17 years and younger with a radiographically confirmed hand fracture. Both emergency physicians and plastic surgeons completed independent CKHR forms for each new hand fracture. The fracture was predicted as “complex” if any one of the six predictors were present on the form. If none of the six predictors were present, the predicted outcome was “simple”. The observed outcome was “complex” if the fracture required surgery, closed reduction, or four or more appointments with a plastic surgeon at three months follow-up. All other fractures were observed outcome “simple”. The classification performance of the CKHR was assessed via sensitivity, specificity, and C-statistic. The kappa coefficient for inter-rater reliability between emergency physicians and plastic surgeons was calculated for each predictor. Results: To date, 102 pediatric hand fractures have been included in this prospective cohort study. Of the 74 observed simple fractures, 49 were predicted as “simple” and 25 were predicted as “complex”. Of the 28 observed “complex” fractures, 25 were predicted as “complex” and 3 were predicted as “simple”. These findings correspond to a sensitivity of 89%, specificity of 66%, and a C-statistic of 0.78. Of the 3 observed “complex” fractures that were predicted as “simple”, i.e. the 3 false negatives, one was a Seymour fracture of the fourth distal phalanx for which the emergency physician did not tick any boxes on the form. Upon further investigation, we learned that the physician had commented that the fracture was open, thus alluding to their acknowledgement of the predictor “open fracture” as being present). This fracture went on to require surgery. The second false-negative fracture was a non-displaced, intra-articular fracture of the fourth metacarpal head that required multiple appointments with the plastic surgeon. The third false-negative fracture was a non-displaced Salter-Harris II fracture of the thumb proximal phalanx without malrotation that received a closed reduction by the emergency physician. The kappa coefficient for inter-rater reliability between emergency physician and plastic surgeon evaluation of predictors varied by predictor from fair to almost perfect agreement. Condylar involvement had the highest kappa coefficient (kappa = 0.85) followed by malrotation (kappa = 0.65) and dislocation (kappa = 0.64). The predictors with the lowest kappa coefficients were displacement (kappa = 0.42), open fractures (kappa = 0.50), and angulation (kappa = 0.53). Conclusion: The Calgary Kids’ Hand Rule had a sensitivity of 89% in a prospective cohort of pediatric hand fractures referred to the Alberta Children's Hospital. The sensitivity could likely be improved with knowledge translation and specific education regarding use of the prediction tool. Emergency physicians and plastic surgeons displayed the lowest inter-rater reliability when assessing displacement, open fractures, and angulation. These predictors may represent areas of future research and physician education to delineate and decrease the discordance between emergency physicians and plastic surgeons.

Seymour Fractures: A Retrospective Review of Infection Rates, Treatment and Timing of Antibiotic Administration.

Seymour fractures are important to recognize and treat promptly because injuries may result in growth disturbance, nail deformity, or infection. We hypothesize that the administration of antibiotics within 24 hours of injury will be associated with a decreased rate of infection. Patients younger than 18 years were included if clinical examination and radiographs demonstrated a Seymour fracture. The timing of antibiotic administration and treatment details were reviewed. The presence of superficial infections or radiographic evidence of osteomyelitis was recorded. A total of 52 patients with 54 fracture that had greater than 30 days of follow-up and were included in data analysis. The average age at the time of injury was 10.2 years. Thirty-four (63%) of 54 patients were most commonly injured secondary to a crush type mechanism. The overall infection rate was 27.3% (15/54 fractures). Among the 29 fractures that received antibiotics within 24 hours of injury, 2 infections (6.9%) were noted at final follow-up. Delayed administration of antibiotics beyond 24 hours postinjury was observed in 17 fractures and was associated with an increased infection rate of 76.5% (13/17, P = 0.000). Early administration of antibiotics within 24 hours of injury is associated with a reduction in the development of infections. Patients with delayed antibiotic administration may be at high risk for early superficial infection or osteomyelitis. This study highlights the importance of early identification and appropriate treatment of Seymour fractures including the prompt administration of antibiotics following injury.

Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations.

Background: Seymour fractures in children are prone to complications without prompt and appropriate treatment. This study investigated outcomes of Seymour fractures with delayed presentations; specifically, if deep infection predisposed to operative treatment, if antibiotic administration improved fracture healing, and if oral clindamycin had fewer treatment failures than oral cephalexin. Methods: A single-institution retrospective cohort study was performed of patients with delayed Seymour fracture presentations (defined as greater than 24 hours post-injury) between 2009 and 2017. Data collected included demographics, time to presentation, infection on presentation, operative treatment, antibiotic use and duration, fracture union, and complications. Statistical testing used logistic regression and Fisher's exact test, with results reported as P-values (P), odds ratios (ORs), and 95% confidence intervals (CIs). Results: There were 73 patients with delayed Seymour fracture presentations, with mean age of 11.1 years (standard deviation: 2.9), with 56 (77%) males, and median time to presentation of 7 days (interquartile range: 3-17). Deep infection on presentation was a risk factor for operative intervention (OR = 34.4, P = .0001, CI, 5.5-217.2). Antibiotic administration protected against the development of a nonunion or delayed union (OR = 0.11, P = .008, CI, 0.021-0.57). Time to antibiotics did not protect against nonunion or delayed union (OR = 0.77, P = .306, CI, 0.37-1.3). Clindamycin had fewer treatment failures than cephalexin (P = .039). Conclusions: Deep infection is a risk factor for operative treatment of Seymour fractures with delayed presentations. Clindamycin is a better antibiotic choice for Seymour fractures that present in delayed fashion.

Treatment of Acute Seymour Fractures.

Seymour fractures are distal phalanx fractures in children with a juxta-epiphyseal pattern. The purpose of our study was to investigate the treatments, outcomes, operative ;indications, and antibiotic choice for acute Seymour fractures (presenting within 24 h of injury), to better define optimal management. We hypothesized that: (1) cephalexin provides adequate antibiotic coverage for acute Seymour fractures; (2) most injuries will achieve good outcomes with management in the emergency department (ED) alone; and (3) indication for operative intervention is unsuccessful or unstable reduction in the ED. We performed a retrospective study of patients under 18 years old treated at a large pediatric hospital from 2009 to 2017 for an acute Seymour fracture. Study outcomes included management and antibiotic type, infection, fracture healing, malunion, physeal disturbance, nail dystrophy, antibiotic failure, and need for unplanned operative intervention. Mean age of patients was 10 years, with 43 males and 22 females sustaining 65 Seymour fractures. Fifty-eight cases (89%) were initially managed in the emergency department. Seven cases were initially managed with an operative intervention that included I&D, open reduction, and K-wire fixation. The most commonly cited surgical indication was unsuccessful closed reduction. Four patients initially managed in the ED required an unplanned operation, usually because of fracture redisplacement. Complications were rare, with superficial infections being most common. Most acute Seymour fractures can be successfully managed in the emergency department if stable reduction is achieved. Level IV, therapeutic.

Musculoskeletal Injuries Resulting from Use of Hoverboards: Safety Concerns With an Unregulated Consumer Product.

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children's hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.

SURGICAL TREATMENT OF Seymour FRACTURES IN CHILDREN AND ADOLESCENTS

To discuss the treatment method and effectiveness of Seymour fracture in children and adolescents. Between January 2013 and November 2015, 26 children and adolescents with Seymour fractures were treated. There were 18 males and 8 females, aged from 1 year and 1 month to 17 years (median, 8.2 years). The injury causes included crush in 14 cases, bruise in 10 cases, and puncture in 2 cases. The thumb was involved in 2 cases, index finger in 1 case, middle finger in 12 cases, ring finger in 6 cases, and little finger in 5 cases. The time from injury to operation was 1-15 hours (mean, 3.2 hours). The patients underwent debridement, nail removal, nail matrix repair, closed reduction and osteosynthesis with Kirschner wires, and splinting in emergency. Kirschner wires and splints were removed at 4 weeks after surgery, and functional exercises were done. All wounds healed by first intention without infection. The follow-up duration was 2-24 months (mean, 12.3 months). The fracture healing was obtained at 1-2 months (mean, 1.4 months) on X-ray film, and no complications of nonunion, malunion, re-displacement, premature epiphyseal closure, or no growth of the nails occurred. Nail deformity developed in 1 case and no re-operation was given. At last follow-up, 1 patient had 10° extension limitation of the distal interphalangeal joint, but the flexion was normal. The motion range of distal interphalangeal joint was 0-75°, showing no significant difference when compared with that of contralateral side (0-78°). The effectiveness for treating Seymour fracture is satisfactory by debridement, nail removal, nail matrix repair, closed reduction and osteosynthesis with Kirschner wires, and splinting in emergency.

Seymour Fractures: Retrospective Analysis and Therapeutic Considerations

To analyze the management of Seymour fractures (juxta-epiphyseal fractures of the terminal phalanx of the finger in conjunction with flexion deformity at the fracture site, laceration of the nail bed, and frequently ungual subluxation) and to determine clinical and radiographic results following operative or conservative treatment. Clinical and radiological results of 24 skeletally immature patients (7 girls and 17 boys; mean age, 8.5 y) with Seymour fractures were evaluated. Assessment after a mean follow-up of 10 years (range, 1-18 y) included the range of motion, the modified Kapandji index, growth disturbance of the effected digit and nail, pain according to the visual analog scale, and patients' satisfaction. Nine patients received nonoperative treatment. Operative management included debridement, open reduction, and fixation in 9. Owing to instability, an additional K-wire passing across the distal interphalangeal joint was used in 5. In 1 patient, the nail was removed. All surgically treated patients received a splint and perioperative cephalosporin. Twenty-three patients out of 24 gained full motion (mean, 80°; range, 65°-90°). The average modified Kapandji index was 5.0 for extension and 4.8 for flexion. Long-term minor growth disturbance of the distal phalanx (seen on radiographs at high amplification only) and nail were noted in 5 patients, and solitary nail dystrophies were observed in 6 patients. Nine of the 11 nail growth irregularities were not a relevant cosmetic problem for the patients. Patients' satisfaction assessment revealed a good clinical outcome. There was neither flexion deformity nor infection in our collective. At the 1-year follow-up examination, the average visual analog score was 0.6 (range, 0-2). According to the literature, the Seymour fracture is an often-underestimated injury, and open cases are prone to infection. Evaluation of the outcome in our collective demonstrated good results with the treatment approaches described. Therapeutic IV.

EXTRA-ARTICULAR TRANSVERSE FRACTURES OF THE BASE OF THE DISTAL PHALANX (SEYMOUR'S FRACTURE) IN CHILDREN AND ADULTS

A series of 25 extra-articular transverse fractures of the base of the distal phalanx (Seymour's fracture) in children, adolescents and adults are presented. Prior to closure of the distal phalangeal epiphysis, the fracture line is usually entirely through the metaphyses, 1 to 2 mm distal to the growth plate. In adults, the fracture line is just distal to the insertion of the extensor tendon. Eighteen of these fractures were treated by closed reduction and splinting and one of these developed an infection and three had mild residual flexion deformities of the finger. Five fractures were treated by K-wire fixation and all healed without complications. Two adult patients presented 4 to 5 weeks after injury with malunion, and of these one underwent refracturing and K-wire fixation with an excellent result.