a b s t r a c t

Open physeal fractures of the distal phalanx of the hallux are the lesser described counterpart to the same frac- ture of the finger, known by its eponym as a “Seymour fracture”. Displaced Salter-Harris phalangeal fractures present with a concomitant nailbed or soft tissue injury. Often these fractures occur in the summer months when open-toe footwear can be worn, however, they may occur indoors as well. Frequently, the injury results from direct axial load of the toe, or “stubbing”, which causes the fracture and associated soft tissue injury. Prompt diagnosis and appropriate treatment is necessary to prevent negative sequelae such as osteomyelitis, malunion, nonunion, or premature growth arrest. In this article, we present a 12 year-old male who sustained an open physeal fracture of the distal phalanx when he “stubbed” his great toe on a bed post. His injury was initially misdiagnosed at an urgent care facility, thereby delaying appropriate intervention and necessitating an operative surgical procedure. Additionally, we review the existing literature discussing these infrequently reported injuries, as well as present key points as they pertain to the diagnosis and management of this injury in the emergency department.

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Introduction

Foot fractures represent 5-13% of all Pediatric fractures and toe frac- tures occur most frequently of all foot fractures [1,2]. While lesser toe fractures typically heal without complication or long-term sequelae, fractures of the hallux require careful consideration due to its role in weight bearing, balance, and pedal motion [1]. Especially in patient with open growth plates, lose examination of distal Soft tissues and the proximal nail fold aids in diagnosing an open injury or Seymour fracture, thereby preventing unnecessary delay in treatment. Clinical signs of bleeding or laceration about the nail fold, or history of those clinical signs must raise concern for this type of open fracture.

Case

A 12 year-old male presented to the senior author’s office eight days after he sustained a an Axial loading injury to his right first toe. He was playing football inside his house and struck his toe against a bedpost. He noted immediate pain and blood underneath his toenail at the time of injury. He was seen and evaluated at an urgent care facility the next day, where radiographs were taken and initially read as negative. After further evaluation by radiology, the patient was notified that the X-rays revealed a fracture through the physis of his right first distal

* Corresponding author.

E-mail address: [email protected] (B. Morris).

phalanx. Upon discovery of his fracture, he was evaluated by his prima- ry care physician, who recommended evaluation with an Orthopedic surgeon. At his Delayed presentation to the senior author, his clinical exam was significant for tenderness to palpation about the base of this right great toe, as well as evidence of previous bleeding at the base of his nailbed. Review of his injury radiographs demonstrated a Salter- Harris Type II fracture of the distal phalanx of his great toe with dorsal gapping at the physis (Fig. 1). Due to his delay in presentation for treat- ment of an open fracture and concern for tissue interposition at the frac- ture site, operative intervention was recommended to the patient and his family. He underwent a nail removal, irrigation and debridement of the fracture site with nailbed repair, fracture reduction and stabiliza- tion with a K-wire (Fig. 2). He was made non-weightbearing until the K- wire was removed at six weeks (Fig. 3) and then transitioned to weightbearing at that time. The patient went on to heal the fracture without any signs of an infection.

Discussion

Severe acute hyperflexion of the hallux interphalangeal joint has been postulated as a mechanism of injury for open physeal fractures of the distal hallux phalanx [3,4]. Crush injury, traumatic laceration, and proximal nail avulsions may also result in a compound injury. Banks et al. [4] reported that avulsion of the proximal nail requires force sufficient to fracture the growth plate [4]. The relationship of bone and nail at the distal phalanx explains the propensity for open

http://dx.doi.org/10.1016/j.ajem.2017.02.015

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1035.e2 B. Morris et al. / American Journal of Emergency Medicine 35 (2017) 1035.e1-1035.e3

Fig. 1. AP, oblique, and lateral radiographs of the right hallux demonstrating physeal disruption and dorsal gapping.

Fig. 2. AP, oblique and lateral radiographs of the right hallux after K-wire fixation.

fracture at that anatomical site and the subsequent risk of infection. The dorsal skin overlying the distal phalanx attaches directly to bony perios- teum without an intervening layer of subcutaneous tissue; the skin be- tween nail and bone is thinnest directly above the epiphyseal growth

plate, with only the germinal matrix of the nail and a shallow layer of dermis present [3].

Outcomes of open distal phalanx fractures are generally good if they are recognized and treated appropriately, however, reported cases of

Fig. 3. AP, oblique and lateral radiographs of the right hallux 6 weeks postoperative.

B. Morris et al. / American Journal of Emergency Medicine 35 (2017) 1035.e1-1035.e3 1035.e3

this injury are sparse. Review of the literature yielded four case series documenting open physeal fractures of the distal phalanx of the great toe, which accounted for 16 patients [3-6]. One study examined pediat- ric hallux fractures and noted 8% of their cohort (N = 317) sustained Open fractures, however, the authors did not specify the proportion of open injuries between distal and proximal Phalanx fractures [1]. 8 of the 16 patients from multiple case reports presented to medical care for evaluation in a delayed fashion, with the delay ranging from 5 days to 14 days. All eight patients developed signs and symptoms consistent with osteomyelitis of the distal phalanx on presentation [3,5,6]. Six of these patients were hospitalized for IV antibiotic administration [3,5, 6]. In patients who present to the hospital with osteomyelitis of the great toe with an open physis, this diagnosis should be considered in the differential diagnosis for the cause of the infection. Noonan et al.

[6] reported three patients with partial closure of the central plantar as- pect of the physis [6]. Two of these patients experienced lateral devia- tion of great toe [6]. None of the patients, however, reported any functional deficits or cosmetically unacceptable deformity.

Prompt diagnosis and treatment of open distal phalanx fractures

prevents unnecessary morbidity, intensive treatment and undue cost. Critical assessment of the soft tissues surrounding the distal hallux aids in accurate diagnosis. Kensinger et al. [5] reported that all of the pa- tients in their series recalled bleeding around the nail at the time of in- jury. Pinckney et al. [3] reported similar findings, all patients in their series gave either a history of a small amount of bleeding from the nail

fold, a laceration proximal to the nail fold, or both [3,5]. Even in the ab- sence of bleeding, fracture through the growth plate should raise suspi- cion for an open fracture due to the close application of skin to bone at the distal phalanx physis. Proper treatment of the injury requires local digital block, removal of nail plate, irrigation and debridement of the fracture site, reduction of the fracture, repair of any nail bed injury and splinting of the digit. A short course of oral antibiotics is typically prescribed as well. This is an injury that all health care providers of the pediatric age group should be aware of in order to avoid complica- tions associated with this injury if left untreated or if treatment is delayed.

References

1. Petnehazy T, Schalamon J, Hartwig C, et al. Fractures of the hallux in children. Foot Ankle Int 2015;36(1):60-3.
2. Kay RM, Tang CW. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg 2001;9(5):308-19.
3. Pinckney LE, Currarino G, Kennedy LA. The stubbed great toe: a cause of occult com- pound fracture and infection. Radiology 1981;138(2):375-7.
4. Banks AS, Cain TD, Ruch JA. Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78(6):310-3.
5. Kensinger DR, Guille JT, Horn BD, Herman MJ. The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop 2001;21(1):31-4.
6. Noonan KJ, Saltzman CL, Dietz FR. Open physeal fractures of the distal phalanx of the great toe. A case report. J Bone Joint Surg Am 1994;76(1):122-5.