SLR - February 2021 - Steven Cooperman
Pediatric Seymour Fractures of the Toe
Reference: Baker CE, Leafblad N, Larson AN. Pediatric Seymour Fractures of the Toe. J Pediatr Orthop. 2021 Jan;41(1):e55-e59.
Level of Evidence: IV - Case series
Scientific Literature Review
Reviewed By: Steven Cooperman, DPM
Residency Program: Highlands/Presbyterian St. Luke’s Medical Center – Denver, CO
Podiatric Relevance: Seymour fractures were initially described in orthopedic hand literature as open injuries of the distal phalanx with either juxta-epiphyseal or physeal Salter-Harris I/II fracture patterns with concomitant injury to the nail bed. Similar injury patterns can occur in the pedal digits as well, resulting in significant complications if not treated appropriately and timely. Due to the lack of available literature evaluating these injuries in the foot, the authors aimed to compare results of pedal Seymour fractures on the basis of type and timing of treatment.
Methods: A retrospective study was performed by reviewing the medical records and radiographs of patients at a single institution who were treated for juxta-epiphyseal fracture or Salter-Harris I/II fractures with concomitant nail bed injury or laceration. Data collected included demographic information, specific type and timing of injury/treatment, hospitalization information, and microbial speciation if available. The primary outcome measure of the study was incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality as described by the patients at final follow-up.
Results: Nineteen patients were included with an average age of 10.9. Average time from injury to diagnosis was 2.9 days and injury to definitive treatment 7.9 days. Twelve patients (63.1 percent) received definitive treatment within 48 hours of injury, with the remaining seven considered “delayed.” Open management was performed in 17 of the 19 patients (89 percent), with three (16 percent) requiring pinning due to unstable reductions. All patients were treated with either oral or intravenous antibiotics of some form, which differed depending on the treating physician. The primary outcome of osteomyelitis occurred in six patients (31.5 percent). There was a significant difference in time from injury to treatment between patients who developed osteomyelitis (22.8 days) versus those who did not (1.1 days), with 6/7 (85.7 percent, P<0.001) of the patients who had “delayed” treatment developing osteomyelitis. There was no correlation between operative intervention and development of osteomyelitis. There were four (21 percent) cases of radiographic evidence of physeal arrest, with three of these patients having developed osteomyelitis. 17/19 patients had confirmed normal function and were without pain at final follow up.
Conclusions: While there are limitations to this study, such as the retrospective nature of the study, lack of standardization in treatment protocol, and the relatively small cohort; this is still the largest case series of pedal Seymour fractures currently described in the literature. Based on the data presented in this study, it is incredibly important to treat these injuries quickly and appropriately as they have a propensity to develop osteomyelitis without early intervention. Treatment should include I&D, stabilization if necessary, and either oral or intravenous antibiotic therapy. In the case of delayed presentation, taking the patient to the OR is likely necessary to eradicate present soft tissue/bone infection and sufficiently debride the injury. Further higher-powered studies with standardized treatment protocols are necessary to ultimately determine the best treatment methods for pedal Seymour fractures, until then, this article should give an appreciation for the importance of early intervention with regards to these injuries.