Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations

Abstract

Background: Seymour fractures in children are prone to complications without prompt and appropriate treatment. This study investigated outcomes of Seymour fractures with delayed presentations; specifically, if deep infection predisposed to operative treatment, if antibiotic administration improved fracture healing, and if oral clindamycin had fewer treatment failures than oral cephalexin. Methods: A single-institution retrospective cohort study was performed of patients with delayed Seymour fracture presentations (defined as greater than 24 hours post-injury) between 2009 and 2017. Data collected included demographics, time to presentation, infection on presentation, operative treatment, antibiotic use and duration, fracture union, and complications. Statistical testing used logistic regression and Fisher's exact test, with results reported as P-values (P), odds ratios (ORs), and 95% confidence intervals (CIs). Results: There were 73 patients with delayed Seymour fracture presentations, with mean age of 11.1 years (standard deviation: 2.9), with 56 (77%) males, and median time to presentation of 7 days (interquartile range: 3-17). Deep infection on presentation was a risk factor for operative intervention (OR = 34.4, P = .0001, CI, 5.5-217.2). Antibiotic administration protected against the development of a nonunion or delayed union (OR = 0.11, P = .008, CI, 0.021-0.57). Time to antibiotics did not protect against nonunion or delayed union (OR = 0.77, P = .306, CI, 0.37-1.3). Clindamycin had fewer treatment failures than cephalexin (P = .039). Conclusions: Deep infection is a risk factor for operative treatment of Seymour fractures with delayed presentations. Clindamycin is a better antibiotic choice for Seymour fractures that present in delayed fashion.

Keywords: Seymour fracture; delayed presentation; finger infection; open fracture.

Figure 1.

Example case of a 5-year-old female patient presenting 21 days after sustaining a Seymour fracture to the left long finger, complicated by mallet-type deformity with hyperemic tissue and purulence communicating to the fracture site. Note. Shown are (a) dorsal (top) and lateral (bottom) clinical views of the affected finger. (b) anteroposterior and lateral radiographs of the affected finger demonstrating osteomyelitis and no evidence of fracture healing, and (c) repeat anteroposterior and lateral radiographs of the affected finger after formal operative treatment with nailplate removal, irrigation, debridement, open reduction, nailbed repair, and Kirschner wire fixation.

Figure 2.

Proposed algorithm for determining appropriate treatment of Seymour fractures with a delayed presentation, on the basis of findings published in the literature (denoted by numerical superscripts corresponding to articles cited in this publication) and results of this study (denoted by an asterisk). Note. Diamond-shaped boxes represent major treatment decision points based on diagnostic findings listed within these boxes. Rectangular boxes represent treatment pathways. Clinical evidence of deep infection is the presence of gross purulence communicating directly with the fracture site. Radiographic findings of osteomyelitis include periosteal reactions, sclerotic bone, and bone erosion. Signs of fracture healing including trabecular bone or callus bridging across the fracture site. Clindamycin dosing is weight-based and typically ranges from 15 to 20 mg/kg/day divided into every 8-hour dosing. PO = per os, oral route of administration; MRI = magnetic resonance imaging.