Problematic Pediatric Hand and Wrist Fractures

Comparison of splinting immobilization and K-wire fixation in children with type II phalange neck fracture

To compare outcomes of type II phalangeal neck fractures in children who received closed reduction followed by splinting immobilization or by K-wire fixation. Furthermore, we analyzed the remodeling potential of residual deformities and the relationship between age and outcomes. Patients in Children's Hospital of Fudan University, Xiamen Hospital were included in the study from October 2015 to October 2018. We compared outcomes between the conservation group and operation group. Remodeling of residual deformities was calculated on a series of anteroposterior and lateral radiography. The correlation between age and outcomes was analyzed using Spearman's rank correlation coefficient. Forty patients (25 males) were enrolled. Nineteen patients had subtype IIa, 19 subtype IIb, and two subtype IIc fractures. Left hands were affected more than right hands, and small finger and proximal phalanx were more frequently involved. There were no significant differences between conservation group and operation group among excellent, good, and fair outcomes. And the outcomes were not significantly different between the IIa and IIb subtypes. An average sagittal remodeling rate was 88.5%, and coronal remodeling rate was 56.71%, respectively, in 13 patients with residual deformities. There was a significant correlation between age and final outcomes. Closed reduction and stable splint fixation may be an effective and economical initial treatment option. Fracture subtype does not seem to be a key factor for choosing treatment options. The fractured phalangeal neck had remodeling potential whether on sagittal or coronal plane. Younger age might be a predictor of better outcomes in children with type II phalanx neck fractures.

Management of Seymour Fractures in Children and Adolescents: A Systematic Review and Meta-Analysis

PURPOSE

Seymour fractures are injuries with a potentially high risk of infection and osteomyelitis. The optimal management of this pediatric open fracture is unknown. We performed a systematic review and meta-analysis to summarize the best evidence for these fractures and determine their optional management based on primary clinical studies.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis was performed. A comprehensive search strategy was applied to the MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and gray literature databases (from May 1966 to April 15, 2020). Studies describing patients under the age of 18 years with Seymour fractures were included. Treatment was grouped based on debridement and antibiotic status as well as the timing of these interventions. The primary outcome was infection. The secondary outcomes included malunion, physeal disturbance, and nail dystrophy.

RESULTS

The searches helped identify 56 records, of which 10 nonrandomized studies met our inclusion criteria, comprising 352 patients and 355 fractures. Early (<48 hours) debridement was associated with significantly less risk of infection (risk ratio [RR] = 0.28 [95% CI, 0.12-0.64]) and malunion (RR = 0.25 [95% CI, 0.07-0.99]). Prophylactic (<24 hours) antibiotics significantly reduced the risk of infection (RR = 0.21 [95% CI, 0.10-0.43]). In addition, prophylactic antibiotics and debridement were associated with a 70% reduction in the risk of infection (RR = 0.30 [95% CI, 0.11-0.83]). Over one-third of patients with delayed presentation (median 8.5 days) were infected at presentation.

CONCLUSIONS

The high-risk nature of Seymour fractures may be mitigated by prompt recognition and early, basic interventions, which can usually be performed in any setting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Type II D Phalangeal Neck Fractures in Children: A Series of 20 Cases Treated According to a Preset Stepwise Algorithm

Introduction Type II phalangeal neck fractures are defined as displaced fractures with bone-to-bone contact at the fracture site. In the type II D subtype, the distal fracture fragment is thin. A review of the literature did not reveal any study investigating the outcome of management of these fractures. Patients and Methods This is a retrospective study of 20 consecutive children with type II D phalangeal neck fractures treated over the past 4 years. Demographic data were reviewed. All cases were managed according to the preset stepwise algorithm. The outcome of management at final follow-up was documented using Al-Qattan's grading system. Results The mean age was 30 months (range 12-80 months). There were 12 males and 8 females. The mean follow-up was 2 years (range 7 months to 3 years). The largest two categories within the management algorithm were patients with minimally displaced fractures treated conservatively ( n = 8) and those with displaced fractures treated with closed reduction and percutaneous K-wire fixation ( n = 9). Fischer exact test was used to compare the outcome in these two groups and the p value was significant ( p = 0.015), indicating a significantly better outcome in the former group. Conclusion Several conclusions were made from the study. Type II D of phalangeal neck fractures tend to occur in young children and the majority involve the middle phalanx. The thinness of the distal fracture fragment makes standard techniques of closed reduction more difficult. However, flexion of the proximal and distal joints appears to be effective in reducing dorsally displaced type II D fractures by closed means. Finally, a more conservative approach to minimally displaced type II D fractures results in a better outcome compared with closed reduction and percutaneous K-wire fixation.

Seymour's Fracture in a 13-years-old Child: A Case Report

Introduction

A nail bed injury concomitant with an underlying physeal injury of the distal phalanx is termed as "Seymour's fracture." These are seemingly innocuous injuries commonly misdiagnosed and are subsequently under-treated. These injuries demand treatment like an open fracture to prevent complications such as infection, growth arrest, and nail dystrophies.

Case Report

A 13-year-old boy suffered Seymour's fracture of the left ring finger distal phalanx after a direct injury from a dodge ball. The fracture was treated with thorough debridement with normal saline, physeal injury reduction through the wound, and fixation with k-wire passed through the tip of the ring finger, metaphysic, physis, and the tip of the k-wire ending in the epiphysis of the distal phalanx. The nail bed was sutured with 3-0 monofilament absorbable sutures. The fracture healed at 3 months and a 1-year follow-up showed a completely formed nail without any deformity.

Conclusion

Excellent outcome was observed with debridement of the wound, nail bed repair, and fixation with k-wire in our case. Nail bed injuries in children should be treated with a high index of suspicion for Seymour's fracture as it necessitates treatment like that of an open fracture to avoid complications.

The optimal management of Seymour fractures in children and adolescents: a systematic review protocol

BACKGROUND

Seymour fractures are open, displaced juxta-epiphyseal fractures of the distal phalanx, with an overlying nail bed laceration that occur in children and adolescents with an open physis. This fracture occurs rarely, but its potential consequences are clinically significant. Due to anatomical particulars and proximity to the growth plate, this open fracture may result in soft tissue infection and osteomyelitis, leading to growth arrest and persistent mallet deformity. At present, there is no consensus as to the optimal management of Seymour fractures. The objective of this study will be to systematically evaluate the existing evidence on the management of Seymour fractures in children and adolescents and to establish what are the most important factors pertaining to an uncomplicated recovery.

METHODS

We designed and registered a study protocol for a systematic review of randomised controlled trials and observational studies. A comprehensive literature search will be conducted (from inception to present) in MEDLINE, EMBASE, CINAHL and Cochrane Library databases. Grey literature will be identified through searching Open Grey and dissertation databases using an exhaustive search strategy. All clinical studies examining the management of Seymour fractures will be included. The interventions (irrigation and debridement; prophylactic antibiotics) and their timings (early vs late) will be compared to no antibiotics and no debridement. Primary outcome measures will be the incidence of superficial and deep infection. Secondary outcomes will include other adverse events such mal-union, non-union, need for re-operation, physeal disturbance and nail dystrophy/atrophy. Two independent reviewers will screen all citations, full-text articles, and abstract data. Conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using an appropriate tool. A narrative synthesis will be performed. If data permits, we will conduct random-effects meta-analysis where appropriate.

DISCUSSION

This review will provide evidence for the management of Seymour fractures, based on a cumulation of existing smaller studies. Due to the rarity of this fracture pattern, included studies are expected to be mainly observational and prone to bias; however, there is value in summarising the evidence to guide clinicians.

SYSTEMATIC REVIEW REGISTRATION

Systematic review registration: PROSPERO CRD42020153726.