> ## Content Index > Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt > Use this file to discover other available public pages before exploring further. # Seymour Fracture: Causes, Clinical Features, & Treatment - URL: https://www.theplasticsfella.com/seymour-fracture/ - Published: 2024-05-11T09:55:25.000Z - Updated: 2024-05-11T09:56:43.000Z - Description: Seymour fractures are open, displaced distal phalangeal fractures in children, often caused by crushing injuries and associated with nail bed damage. Treatment includes irrigation, debridement, reduction, fixation, and antibiotics. - Author: PlasticsFella - Tags: Upper Limb #### Summary Card [****Definition** ](https://www.theplasticsfella.com/seymour-fracture/#definition-of-seymour-fracture)A Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nailbed injury. [****Anatomy** ](https://www.theplasticsfella.com/seymour-fracture/#anatomy-of-seymour-fracture)They present as mallet fingers with a flexion deformity due to the level of flexor and extensor tendons at the distal phalanx. [****Clinical Features** ](https://www.theplasticsfella.com/seymour-fracture/#clinical-features-of-seymour-fracture)Crush injuries associated with a nail plate avulsion and proximal nail bed interposition at the fracture site. [****Investigations** ](https://www.theplasticsfella.com/seymour-fracture/#investigations-for-seymour-fracture)X-rays are required for adequate diagnosis with distinct features seen on the lateral view. [****Treatment** ](https://www.theplasticsfella.com/seymour-fracture/#treatment-of-seymour-fracture)Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics. [****Complications** ](https://www.theplasticsfella.com/seymour-fracture/#complications-of-seymour-fracture)Include osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances of the distal phalanx. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow, South Africa. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow, Scotland. --- ## Definition of Seymour Fracture ****Key Point** A Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nailbed injury. A **Seymour fracture** is a displaced, open fracture of the juxta-epiphyseal region of the distal phalanx, with an overlying nail bed injury that occurs in skeletally immature individuals. The image below illustrates a Seymour fracture. ![Seymour fracture, Nailbed Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--4-.png) Seymour fracture It is associated with the avulsion of the **nail plate** and a concomitant laceration of the **nail bed** due to the proximity of the nail bed to the fracture site. It presents as either: - Salter-Harris Type I - Salter-Harris Type II - "Juxta-epiphyseal" occurs at the metaphysis, slightly distal to the physis 💡 ****Tip:** Seymour Fractures are often mis-diagnosed. Always be careful of a proximal nail bed injury! --- ## Anatomy of Seymour Fracture ****Key Point** Seymour fractures are caused by crushing injuries and present as mallet fingers with a flexion deformity. The Seymour Fracture is considered a **bony** and **soft tissue injury**. In relation to the bone, there is a predisposition for this fracture in the distal phalanx [(Krusche-Mandl](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com), 2013) due to: - Weakness of the **epiphyseal-metaphyseal** junction. - Angulation of the **diaphysis** on the **epiphysis**. - Insertion sites of the flexor and extensor tendons into the distal phalanx. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--5-.png) The injury presents as a **pseudomallet**, characterized by a flexion deformity of the distal phalanx, due to asymmetric tendon insertions. - **Extensor** tendon attaches to the **epiphysis** of the proximal fracture fragment. - **FDP** tendon attaches to the **metaphysis** of the distal fragment. This configuration results in opposing forces at the fracture site, which hinders proper healing. The image below illustrates the anatomy of the Seymour Fracture. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Seymour-Fracturee-Anatomy.png) Seymour Fracture Anatomy 😎 ****Fun Fact:** Extensor tendon rupture is uncommon in children because the epiphyseal plate is weaker than the tendon ([Krushe-Manndl,](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com) 2013). --- ## Clinical Features of Seymour Fracture ****Key Point** Seymour fractures have a variety of presentations from subtle nailbed injuries to grossly displaced and exposed fractures. It can be commonly misdiagnosed. A Seymour Fracture has a typical **history** of a crush injury. In terms of **clinical examination**, common findings include: - Nail bed injury with an avulsed nail plate (often lying superficial to the eponychial fold) - Skin laceration - 'Pseudomallet' deformity due to flexion forces > extensor forces. - Elongation of the lunula. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Seymour-Fractures.png) Clinical Features of a Seymour Fracture 😎 ****Fun Fact:** The middle finger is the most commonly involved finger ([Lopez](https://pubmed.ncbi.nlm.nih.gov/34842086/?ref=theplasticsfella.com), 2021). --- ## Investigations for Seymour Fracture ****Key Point** X-rays, especially the ****lateral view** are key to identifying Seymour fractures. The identification of Seymour fractures is key to ensuring adequate and appropriate treatment. X-ray is the imaging modality of choice, key radiological findings are: - **Posteroanterior**: may appear normal. - **Lateral**: widened physis or displacement between epiphysis and metaphysis. They may also be a flexion deformity at the fracture site. The image below illustrates Seymour fracture on the lateral view of an X-ray. ![Seymour fracture on the lateral view of an X-ray, Diagnosing Seymour Fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images.png) Seymour fracture on the lateral view of an X-ray 💡 ****Tip:** A lateral x-ray distinguishes between an extensor tendon rupture and a juxta-epiphyseal Seymour fracture. --- ## Treatment of Seymour Fracture ****Key Point** Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics. Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics ([Krushe-Manndl,](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com) 2013). The recommended management of Seymour fractures can be looked at from both a soft tissue and bone perspective ([Lin](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com), 2019): **Soft Tissue** **Repair:** - Nail plate removal. - Extraction of the germinal matrix entrapped at the fracture site through hyperflexion of the digit or distal fragment retraction - Irrigation and selective debridement **Fracture reduction.** - **K-wire** if the fracture is **unstable** or concern of patient non-compliance. - **Splinting** the DIPJ if stable fracture after reduction and compliant patient. - **Tip**: The nail aids in stable reduction by acting like a splint ![K-wire fixation of Seymour fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--3-.png) K-wire fixation of Seymour Fracture It is worth noting, other techniques have been described. For example, late infected Seymour fractures can be treated by a one-suture technique that holds the distal phalanx in place. This technique avoids the need for K-wires in the setting of infection ([Englert](https://pubmed.ncbi.nlm.nih.gov/36974281/?ref=theplasticsfella.com), 2022). 💡 ****Tip:** The absence of fracture healing can be seen on radiographs - by trabecular bone or callus bridging across the fracture site ([Samade](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com), 2021). --- ## Complications of Seymour Fracture ****Key Point** Complications include osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances of the distal phalanx. The primary concern regarding Seymour Fractures is the **interposition of the germinal matrix is between fracture fragments -** resulting in Osteomyelitis, Non-union, or Malunion. Factors that lead to increase complications include: - Delayed Treatment - Insufficient debridement. - Incomplete fracture reduction. - Inadequate antibiotic treatment. A Seymour fracture presenting after 24 hours is considered a delayed fracture and has a greater risk of infection ([Samade](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com), 2021). An algorithm for the approach for delayed Seymour fractures can be found [here](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com). 😎 ****Fun Fact:** Premature physeal closure is usually due to infection rather than direct injury to the growth plate ([Lin](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com), 2019). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition and Anatomy of Seymour Fractures:** You've learned that a Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nail bed injury, commonly occurring in children. ****2\. Causes and Presentation of Seymour Fractures:** You now understand that these fractures often result from crushing injuries and are characterized by symptoms such as mallet fingers with a flexion deformity at the distal phalanx. ****3\. Seymour Fracture Diagnostic Approaches:** You're aware that X-rays, particularly lateral views, are crucial in diagnosing Seymour fractures. ****4\. Treatment Modalities for Seymour Fractures:** You've learned about treatment approaches for Seymour fractures, which includes irrigation, debridement, reduction, fixation, and antibiotics. ****5\. Potential Complications of Seymour Fractures:** You understand possible complications such as osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances. --- ## Further Reading 1. Perez-Lopez LM, Parada-Avendaño I, Cabrera-Gonzalez M, Fontecha CG. [Seymour fracture: Better do not underestimate it](https://pubmed.ncbi.nlm.nih.gov/34842086/?ref=theplasticsfella.com). Jt Dis Relat Surg. 2021;32(3):569-574\. doi: 10.52312/jdrs.2021.330\. Epub 2021 Nov 19\. PMID: 34842086; PMCID: PMC8650660. 2. Kiely AL, Nolan GS, Cooper LRL. [The optimal management of Seymour fractures in children and adolescents: a systematic review protocol](https://pubmed.ncbi.nlm.nih.gov/32576259/?ref=theplasticsfella.com). Syst Rev. 2020 Jun 23;9(1):150\. doi: 10.1186/s13643-020-01407-5\. PMID: 32576259; PMCID: PMC7313162. 3. Krusche-Mandl I, Köttstorfer J, Thalhammer G, Aldrian S, Erhart J, Platzer P. [Seymour fractures: retrospective analysis and therapeutic considerations](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com). J Hand Surg Am. 2013 Feb;38(2):258-64\. doi: 10.1016/j.jhsa.2012.11.015\. PMID: 23351909. 4. Seymour N. [Juxta-epiphysial fracture of the terminal phalanx of the finger](https://pubmed.ncbi.nlm.nih.gov/5939484/?ref=theplasticsfella.com). J Bone Joint Surg Br. 1966 May;48(2):347-9\. PMID: 5939484. 5. Lin JS, Popp JE, Balch Samora J. [Treatment of Acute Seymour Fractures](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com). J Pediatr Orthop. 2019 Jan;39(1):e23-e27\. doi: 10.1097/BPO.0000000000001275\. PMID: 30358692. 6. Samade R, Lin JS, Popp JE, Samora JB. [Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com). Hand (N Y). 2021 Sep;16(5):686-693\. doi: 10.1177/1558944719878846\. Epub 2019 Oct 9\. PMID: 31597480; PMCID: PMC8461200. 7. Reyes BA, Ho CA. [The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration](https://pubmed.ncbi.nlm.nih.gov/26327401/?ref=theplasticsfella.com). J Pediatr Orthop. 2017 Jun;37(4):247-253\. doi: 10.1097/BPO.0000000000000638\. PMID: 26327401. 8. Farid M, Shibu M. [A rare case of Seymour fracture in an adult with non-fused growth plates](https://pubmed.ncbi.nlm.nih.gov/34104672/?ref=theplasticsfella.com). Case Reports Plast Surg Hand Surg. 2021 May 19;8(1):72-75\. doi: 10.1080/23320885.2021.1927738\. PMID: 34104672; PMCID: PMC8143599. 9. Englert EG, Tooley T, Weisz K, Shapiro P. [Suture Fixation of Subacute Pediatric Seymour Fractures](https://pubmed.ncbi.nlm.nih.gov/36974281/?ref=theplasticsfella.com). J Hand Surg Glob Online. 2022 Dec 7;5(2):231-233\. doi: 10.1016/j.jhsg.2022.10.013\. PMID: 36974281; PMCID: PMC10039310. 10. Abzug JM, Kozin SH. [Seymour fractures](https://pubmed.ncbi.nlm.nih.gov/24206995/?ref=theplasticsfella.com). J Hand Surg Am. 2013 Nov;38(11):2267-70; quiz 2270\. doi: 10.1016/j.jhsa.2013.08.104\. PMID: 24206995. ---