Updated: 6/24/2021

Seymour Fracture

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  •  summary
    • Seymour Fractures are displaced distal phalangeal physeal fractures with an associated nailbed injury.
    • Diagnosis is made clinically with the presence of nail plate lying superficial to the eponychial fold and radiographs potentially showing widened physis or displacement between the epiphysis and metaphysis.
    • Treatment is usually antibiotics, open reduction and pinning across DIPJ with nailbed repair.
  • Epidemiology
    • Incidence
      • 20% to 30% of phalangeal fractures involve the physis in children
    • Anatomic location
      • middle finger injury is most common
      • type of the distal phalangeal physeal fracture:
        • metaphyseal fractures 1 to 2 mm distal to the epiphyseal plate
        • Salter-Harris I fractures
        • Salter-Harris II fractures
      • type of nailbed injury:
        • nailbed laceration
        • nail plate subluxation
        • interposition of soft tissue at fracture site (usually germinal matrix)
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • direct trauma or crush injury (e.g. caught in door, heavy object or sport)
      • pathoanatomy
        • similar mechanism to mallet finger in adults
        • injury causes flexed posturing of the distal phalanx
        • deformity results from an imbalance between the flexor and the extensor tendons at the level of the fracture
        • imbalance occurs due to different insertion sites of flexor and extensor tendons
          • extensor tendon inserts into the epiphysis of the distal phalanx
          • flexor tendon inserts into metaphysis of the distal phalanx
        • widened physis likely to have interposed tissue in the fracture site
  • Presentation
    • Physical exam
      • apparent mallet deformity
      • echymosis and swelling
      • nail plate lying superficial to the eponychial fold
  • Imaging
    • Radiographs
      • recommended views
        • PA
          • may appear normal
        • lateral
      • findings
        • widened physis or displacement between epiphysis/metaphysis
        • flexion deformity at fracture site
          • seen on lateral view
  • Differential 
    • Mallet finger
      • pediatric mallet finger is usually osseous avulsion (SH III and SH IV)
      • mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not enter DIPJ)
  • Treatment
    • Nonoperative
      • closed reduction and splinting
        • indications
          • minimally displaced, closed fracture
          • no interposition of soft tissue at fracture site
    • Operative
      • closed reduction and pinning across DIPJ
        • indications
          • displaced, closed fracture
          • no interposition of soft tissue at fracture site
      • open reduction and pinning across DIPJ, nailbed repair
        • open management has fewer complications than closed management
        • indications
          • open fracture
        • technique
          • hyperflexion of the digit will permit removal of the interposed soft tissue from the fracture site
          • thorough irrigation and debridement
          • anatomical reduction and retrograde k-wire fixation crossing the fracture site and DIP joint
          • nailbed injury repair
  • Complications
    • Nail dystrophy
    • Growth disturbance of the distal phalanx and nail
    • Secondary fracture displacement
    • Chronic osteomyelitis (failure to treat as open fracture)
    • Flexion deformity
  • Prognosis
    • Operative intervention is warranted to ensure that there is no interposed tissue in the fracture site
    • Failure to recognize injury may result in:
      • nailplate deformity
      • physeal arrest
      • chronic osteomyelitis
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