Surgical Treatment of Pediatric Seymour Fractures of the Great Toe.

Background: Seymour fractures are open, distal phalangeal physeal fractures with an associated nail-bed injury that occur in pediatric patients1. Although first described in the finger, an equivalent injury can occur in the distal phalanx of the great toe, often via a direct axial load at the apex of the toe, resulting in Salter-Harris type-I or II or juxta-epiphyseal fractures with a concomitant nail-bed laceration2-12. Closed reduction and splinting were initially recommended in these fractures1; however, they are now commonly treated with formal irrigation and debridement and the administration of prophylactic antibiotics in the acute setting in order to minimize the risk of complications such as infection10-12. To our knowledge, there are no detailed resources describing this surgical technique. Description: With the patient in the supine position, a nonsterile tourniquet is applied, the operative foot is thoroughly cleansed and prepared in a sterile field, and the operative extremity is exsanguinated. A digital block is then administered. With use of blunt instruments, the nail plate is removed or lifted to allow visualization of the underlying structures. A lacerated nail bed, or germinal matrix, will likely be observed, appearing as a glistening and highly vascularized soft-tissue structure at the proximal end of the nail, responsible for nail growth. Small incisions near the extension creases of the distal interphalangeal joint may be required to retract the eponychial fold and inspect the laceration and fracture site. Next, thorough irrigation and debridement are performed to clean the fracture site and remove any contaminants or nonviable tissues. The fracture is then manually reduced under direct visualization, ensuring proper alignment of bone fragments. Any interposed soft tissue, such as the germinal matrix or periosteum, is extricated from the fracture site with use of fine instruments. If the fracture is deemed unstable, percutaneous pinning with 0.045-in or 0.062-in Kirschner wires is performed to stabilize the fracture. Kirschner wires are inserted through the skin and driven across the fracture site and distal interphalangeal joint. Appropriate placement of pins is confirmed on fluoroscopy, and the nail bed is repaired with use of absorbable sutures. In cases with gross contamination or osteomyelitis, it is prudent to avoid pin fixation. A sterile dressing is applied, and the foot is immobilized in a well-padded short-leg cast or splint to protect the fracture and pin and to maintain alignment. Postoperatively, the patient is given a short course of oral antibiotics (e.g., cephalosporin) to prevent infection. Radiographic images are obtained at the first regular follow-up appointment (within 1 week postoperatively), and the Kirschner wires are removed once sufficient healing has occurred (typically 4 to 6 weeks postoperatively). Alternatives: Alternative treatments include nonoperative treatment with thorough irrigation, antibiotic administration, and closed reduction. Rationale: This technique provides direct visualization and reduction of the fracture, unlike closed reduction and splinting, which may result in re-displacement, nonunion, and inadequate stabilization. The ability to perform thorough irrigation and debridement reduces the risk of infection, a common complication in Seymour fractures, and enhances overall healing outcomes1. Percutaneous pinning with Kirschner wires provides superior stability compared with splinting or suture fixation alone, particularly in unstable or displaced fractures. Fixation with use of a Kirschner wire ensures that the fracture remains properly aligned throughout the healing process, preventing malunion and deformity. Compared with suture stabilization alone, this method offers better maintenance of reduction, especially in cases with substantial displacement or instability. Given these advantages, pin or Kirschner wire fixation is preferred in most cases, as it provides more reliable stabilization, minimizes the risk of complications, and improves overall healing outcomes. Expected Outcomes: Patients are expected to have a high rate of successful recovery with minimal long-term sequelae, ensuring a return to normal function and cosmesis of the toe. Studies have shown that early and definitive surgical intervention significantly reduces the risk of complications, such as infection, growth arrest, malunion, and nail deformity2-12. In a cohort of patients undergoing this procedure, there were no occurrences of growth arrest or notable nail deformity during follow-up11. Baker et al. demonstrated that patients who underwent treatment within 48 hours had a significantly lower rate of osteomyelitis and other adverse outcomes12. Important Tips: Greater awareness of this fracture pattern can prevent delays in treatment and complications.Consider hyperflexion of the great toe to remove interposed tissue from the fracture site.Kirschner wires with a smaller diameter can be utilized if the phalangeal anatomy is small. Acronyms and Abbreviations: K-wire = Kirschner wireI&D = irrigation and debridementDIP = distal interphalangeal jointAP = anteroposteriorMRI = magnetic resonance imaging.