Suture Fixation of Subacute Pediatric Seymour Fractures

Abstract

Seymour fractures are common injuries in the pediatric population. High rates of deep infection have been reported due to delayed presentation and subsequent treatment. This report describes the case of a 13-year-old male wrestler who presented 1 month after a finger injury that was later diagnosed as a subacute Seymour fracture with osteomyelitis. The patient underwent irrigation and debridement and fracture reduction stabilized with nonabsorbable suture fixation. After 6 weeks of intravenous antibiotics, the patient was recovering well, with radiographic evidence of fracture healing and clearance of infection. This case highlights the use of a single suture as a treatment option for fixation of unstable Seymour fractures with delayed presentation. The management of acute open distal phalangeal physeal fractures is well described in the literature; however, further investigations are warranted into the optimal management of chronically infected digits with unstable Seymour fractures.

Nail bed trauma occurs frequently, with more than 4.8 million patients presenting to the emergency departments each year with fingertip injuries.¹ Phalangeal fractures are especially common in pediatric patients, with an incidence of 185 per 100,000 in children aged 5–14 years.²

Seymour fractures, first described by Neville Sheffield in 1966, are distal phalangeal fractures in which the displaced metaphysis disrupts the overlying nail bed, resulting in an open fracture.³ Incarceration of the germinal matrix can oppose reduction and substantially increase the risk of infection, malunion, and permanent nail deformation. Up to 11% of patients who present more than 24 hours after injury develop deep infections.^2,4

The treatment of acute Seymour fractures typically involves administration of antibiotics followed by removal of the nail, extraction of the germinal matrix and other interposed soft tissue by hyperflexion of the digit, and irrigation and debridement (I&D). Retrograde placement of a 0.9-mm (0.035-in) or 1.1-mm (0.045-in) Kirschner wire is often necessary to maintain the reduction.^2,4 Delayed presentation poses a more difficult challenge as no formal consensus regarding optimal management of these injuries. Review of the literature produced only a single institution review with treatment recommendations for this injury. Samade et al² recommended I&D, fracture reduction, and Kirschner wire fixation when there is evidence of deep infection. We report the case of a pediatric patient who presented with a subacute Seymour fracture with deep infection who underwent I&D and a fracture reduction that was stabilized with nonabsorbable suture fixation.

The patient’s legal guardian was informed that their child’s case offered valuable educational content. They subsequently provided consent for publication of data associated with the care that the patient received.

Case Report

A right-handed dominant 13-year-old male wrestler presented to the emergency department with 1 month of pain and swelling in the middle finger of the left hand after a teammate stepped on it during practice. The patient reported immediate pain and swelling with discoloration of the nail. Persistent purulent drainage that was refractory to oral antibiotics prompted an escalation of care. On examination, the patient had erythema and tenderness in the middle finger distal interphalangeal joint (Fig. 1). Radiographs at that time revealed widening and displacement of the physis of the distal phalanx (Fig. 2). Magnetic resonance images revealed resorption or osteolysis at the physis of the distal phalanx with postcontrast enhancement, which was consistent with a subacute Seymour fracture with associated paronychia and underlying osteomyelitis (Fig. 3).

Figure 1.

Left middle finger of the patient at initial presentation.

Figure 2.

Anteroposterior and lateral radiographs of the left hand of the patient at initial presentation.

Figure 3.

Coronal and sagittal magnetic resonance imaging short tau inversion recovery sequences at initial presentation.

The next day, the patient was brought to the operating room. The nail was removed, revealing periosteal tissue adjacent to the germinal matrix which was excised. Two oblique incisions were made to retract the nailfold. A scant amount of purulence was encountered and cultures were obtained. There was evident motion at the fracture site and bone loss along the distal phalanx, which was debrided with a dental pick. A copious amount of irrigation was performed with antibiotic solution. Given the gross infection at the fracture site, the decision was made to use a 4-0 nylon suture as an external fixating modality to hold the distal phalanx in a stable, extended position. The suture was passed through the dorsal pulp and tied loosely in a knot. The suture was then directed through the skin at the level of the middle phalanx and a knot was tied with enough tension to hold the fracture in a reduced position (Fig. 4). The nail bed was subsequently dressed with mesh gauze and a sterile compressive bandage reinforced using a volar fiberglass orthosis secured with a self-adherent wrap.

Figure 4.

Maintenance of fracture reduction with 4-0 nylon suture extending from dorsal pup to skin superficial to the middle phalanx.

After surgery, a peripherally inserted central catheter was placed. Initially, the patient was treated empirically with vancomycin until cultures subsequently grew methicillin-susceptible Staphylococcus aureus, at which time he was transitioned to a 6-week course of daptomycin. Upon discharge, the patient was followed up every 2 weeks. At his first postoperative visit, his finger was placed in a stack orthosis. His dorsal suture was removed at the 6-week follow-up, and orthosis fabrication was continued for another week. The patient did not show any signs of drainage or persistent infection. Radiographs revealed alignment maintenance with evidence of fracture healing (Fig. 5).

Figure 5.

Anteroposterior and lateral radiographs of the patient’s left hand at 8 weeks after surgery.

Discussion

Seymour fractures of the hand are relatively common but frequently missed in pediatric patients.⁴ Although the management of acute Seymour fractures is well described in the literature, there is less consensus regarding the optimal treatment for delayed presentations.^2,5 In this case report, we present a treatment option for late-presenting, infected Seymour fracture using a single nonabsorbable suture to maintain fracture reduction.

Samade et al² evaluated 73 patients with Seymour fractures presenting more than 24 hours after injury. Patients in their cohort underwent Kirschner wire fixation after I&D. The investigators found that delayed presentations increased the likelihood of surgical intervention and that clindamycin is the optimal oral antibiotic in the absence of speciation or drug sensitivities.² Compared with an average presentation of 7 days after injury in their cohort, our patient presented 4 weeks after the inciting trauma.

Controversy exists regarding the optimal means of immobilizing Seymour fractures. Although Kirschner wire fixation is often necessary to maintain reduction of the distal phalanx in the acute setting, to our knowledge, no formal randomized control trial has been performed to investigate the use of Kirschner wire fixation versus orthosis fabrication.^4,6 A recent systematic review encompassing 206 patients from 5 case series and 3 single-center retrospective cohort studies found that Kirschner wire fixation was associated with higher rates of physeal disturbance but lower rates of infection, fracture-displacement, and flexion deformity. However, these conclusions were limited by the absence of formal statistical analysis because of the heterogeneity of the included studies.⁷

The use of suture-only fixation for juxta-epiphyseal distal phalangeal fractures has been previously described in the acute setting.^8,9 In a series of 5 patients, Reid et al⁸ described an “all suture technique” to maintain the reduction of Seymour-type fractures of the great toe as a reliable alternative to Kirschner wire fixation. Another series study by Cha et al⁹ described a similar suture-based alternative to traditional Kirschner wire fixation for unstable, acute Seymour fractures of the finger. They reported successful fracture healing at the 1-year follow-up. However, unlike our case, their patients presented 28–40 hours after injury and did not have fulminant infections.⁹ Although it was evident that I&D and antibiotics were necessary for our patient, we were concerned about prolonged Kirschner wire fixation and the subsequent risk of deep hardware infection prompting the use of this treatment modality. These studies suggest that all-suture fixation is a reasonable alternative to Kirschner wire fixation for Seymour fractures with the theoretical benefit of mitigating possible infection risks associated with prolonged Kirschner wire fixation. However, further studies are warranted to investigate infection clearance rates using the all-suture technique versus Kirschner wire fixation or orthosis fabrication alone in active osteomyelitis.

Chronically infected physeal injuries provide a unique challenge to hand surgeons, and little has been published regarding the optimal medical management to accompany surgical intervention in this unique setting. A retrospective review by Rask et al¹⁰ found that when antibiotics were administered more than 24 hours after the inciting trauma, the risk of both superficial infection and osteomyelitis increased by 76.5%. Our literature review was unable to find articles discussing optimal antibiotic choice and duration of treatment for patients with chronically infected Seymour fractures. It is likely that the antibiotic of choice of infectious disease specialists to treat chronically infected Seymour fractures varies by institution because of regional differences in drug sensitivities toward common pathogens. Our patient appeared to clear the infection after a 6-week course intravenous daptomycin that was prescribed by the pediatric infectious disease specialist from our institution. Further investigation is warranted into the optimal duration of treatment and efficacy of intravenous versus oral antibiotics for subacute and chronically infected Seymour fractures.

This case report highlights the use of a single suture as a treatment option for fixation of unstable Seymour fractures with delayed presentation to accompany I&D and appropriate antibiotic therapy. The management of acute open distal phalangeal physeal fractures is well described in the literature; however, further investigation into the optimal management of chronically infected digits with unstable Seymour fractures is warranted.