Pt is a 10 yo male that tripped over his dog and his great toe struck their wood floor. X-rays were obtained which revealed what I thought was a SH II fracture. I did a digital block and attempted to reduce. Little progress was made after several attempts. At this point I reached out to the on call MD and while waiting to hear back I contacted my supervising MD. He stated that it looked like a Seymour fracture, typically distal phalanx finger fractures but there is no other name for these fractures in toes. I am sure at some point I answered a question about a Seymour fracture but it did not come to recollection so I googled it. About this point the on call MD called back and I told him what I had and he could not recall the treatment of a Seymour fx either. I explained what I had found. A Seymour Fx requires that the germinal matrix of the nail bed be removed from the Physis. They almost all go to the OR and may require ABX either oral or IV. I was ultimately recommended that he go to ER. I put him in a post op shoe and he ended up going to surgery the following Tuesday.
Seymour Fx treatment per our Surgeons:
- The key is the ‘V’ sign on lateral xray. Wider dorsally than it is palmarly / plantarly. Clinically, this is good too – looks like disruption between nail and nail fold. Usually a crush mechanism of sorts.
It is an open fracture of the physis
This requires extrictation of the interposed nail bed from the physis, I+D, and nail bed repair. Antibiotics are dealer’s choice but likely depend on toe vs finger, cleanliness, etc. Physician preference too. I don’t see the downside.
If the PA is comfortable and experience this can be attempted in UC but typically these go to the OR. To me, I take them the next available OR day, which for this Friday case would have also been on a Tuesday. Kid should do fine.
- I would vote, in UC, if it’s going to wait for few days till OR, then abx on board would be a good idea.
Note: This post was submitted to me by a work colleague Brian Savage, PA-C.
Sam Dyer, PA-C, MHS