Displaced Open Physeal Fractures of the Distal Phalanx (Seymour Fracture): Does Delay in Diagnosis and Treatment Result in Worse Outcomes?
Alfred Lee, B.A., Jason D. Wink, M.D., M.S., Benjamin Chang, M.D., Ines C. Lin, M.D..
University of Pennsylvania, Philadelphia, PA, USA.
Seymour fractures can present in an immediate or delayed fashion to both the clinic and emergency room. We present our experience with the treatment of Seymour fractures at a large urban pediatric tertiary care center.
A retrospective review (2007–2018) of patients who received definitive treatment of Seymour fractures at the Children’s Hospital of Philadelphia (CHOP) was performed. Demographic, injury- and treatment-related, and outcome data were collected. Complications included pin or surgical site infection (SSI), physeal disruption, malunion, secondary fracture displacement, and nail deformity. Statistical analysis (t-test, Fisher’s exact) was performed to identify significant differences (p<0.05) in outcomes between location and timing of initial presentation.
65 patients (49 M/16 F) were included. Mean age was 11.6 ± 3.2 years (range, 3-17). Mean time from injury to initial presentation to any healthcare provider was 2.6 ± 5.2 days (range, 0-25). 75.4% (n=49) presented to an emergency room, 10.8% (n=7) to an outpatient office, and 12.3% (n=8) to urgent care. Of the 46 patients presenting initially to an outside institution, 14 (30.4%) were transferred to CHOP. There was no significant difference in mean time from injury to initial presentation for patients presenting initially to CHOP, transferred from outside hospitals, and treated at outside hospitals (p=0.186). Sports and crush were the most common mechanisms of injury. The most commonly injured fingers were middle (n=20), ring (n=18) and small (n=13) fingers. Patients treated initially at an outside institution (n=32) most commonly received splinting (65.6%) and/or antibiotics (25%). Definitive management at CHOP consisted of open reduction (72%), closed reduction (9.2%), and trial of conservative management requiring subsequent surgery (18.4%). 93.9% (n=62) underwent percutaneous pinning. All patients had radiographic evidence of healing. Post-operatively, 7.6% (n=5) had SSI and 18% (n=12) had physeal disruption. 7 patients had documented nail deformity. No instances of pin infection, malunion, or secondary displacement were reported. Delayed presentation (>24 hours) was associated with clinical signs of infection prior to surgery (p<.001) and longer mean post-operative antibiotic duration (17.2 days vs 8.8 days, p=0.025). Timing and place of initial presentation were not significantly associated with SSI, physeal disruption, or nail deformity.
Delayed presentation is associated with greater risk of infection at time of surgery and a longer course of post-operative antibiotics. In our experience, surgically managed Seymour fractures have high rates of fracture healing and low rates of post-operative infection, physeal disruption, and nail deformity, even in delayed care.
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