SLR - October 2021 - Veronika Boulantsova

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-d59.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Veronika Boulantsova, DPM 
Residency Program: Montefiore Medical Center – Bronx, NY 

Podiatric Relevance: Seymour fractures are Salter Harris I/II fractures involving the physis or juxta-epiphysis of the distal phalanx with concomitant nail bed laceration. Initially these fractures were described in the finger with limited literature addressing equivalent fractures of the toe. Given subtle clinical appearance of these injuries, they are difficult to recognize and are often overlooked by the treating clinician. Without proper early treatment significant complications may ensue including nail dystrophy, premature physeal arrest and osteomyelitis due to the open nature of the injury. This retrospective case series aims to bring awareness to Seymour fractures of the toe and to assess complication rates of such injuries. 

Methods: A level IV retrospective case series was conducted. Inclusion criteria comprised of patients with juxta-epiphyseal fractures or Salter Harris I/II fractures of the toe with concomitant nail bed laceration. Nineteen patients met the inclusion criteria for review. The average time from injury to definitive treatment was recorded. Definitive treatment included incision and drainage, fracture stabilization and antibiotic management. The primary outcome assessed was the presence of osteomyelitis as determined by imaging studies or intraoperative purulence in the bone at the fracture site. Secondary outcomes assessed included premature physeal arrest, development of nail dystrophy and self-reported functionality. 

Results: No patient who received acute definitive management (within 48 hours) went on to develop osteomyelitis. Six of seven (85.7 percent) patients who had delayed definitive treatment (>48h) developed osteomyelitis, which was significant ( p<0.001). There were four cases (21 percent) of radiographic evidence of physeal arrest. Physeal arrest had no significant association with days from injury to treatment. In total 17 cases (89.5 percent) had normal appearing nail and one developed dystrophic nail on follow up. Seventeen cases had confirmed normal function with normal arc of motion and no pain on weightbearing on final follow up. 

Conclusions: This study found that delayed diagnosis and delayed definitive treatment of Seymour fractures in the toe was associated with statistically significant incidence of osteomyelitis. Thus, adolescence with a history of stubbed great toe should be presumed to have Seymour fracture until proven otherwise. Formal treatment including incision and drainage, stabilization and a course of antibiotics should be initiated in the emergency department. Limitations of this study include its retrospective nature and small cohort size. 

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