Seymour Fractures Revisited: Recognition and Management of an Open Physeal Distal Phalanx Injury

Seymour fractures are pediatric distal phalanx physeal injuries of the fingers and toes associated with disruption of the nail bed. Despite increasing recognition, they are still frequently misdiagnosed, leading to delayed treatment and preventable morbidity. This review synthesizes contemporary literature on the definition, clinical and radiographic diagnosis, differential diagnoses, management, and outcomes of Seymour fractures. Diagnosis relies on maintaining a high index of suspicion in skeletally immature patients presenting with distal interphalangeal (DIP) joint flexion, bleeding at the nail fold, or proximal nail plate displacement superficial to the eponychial fold. Anteroposterior (AP) and lateral radiographs may demonstrate physeal separation; however, equivocal imaging findings should not override clinical evidence of nail-unit violation. In acute presentations, management should follow open fracture principles, including early antibiotic administration, irrigation and debridement, removal of interposed germinal matrix or nail bed tissue from the fracture site, anatomic reduction, and selective stabilization when reduction is unstable; however, management of delayed presentations without clinical infection may require a more individualized approach. Contemporary literature does not support routine pinning of every fracture, but delayed presentation, instability, and infection lower the threshold for operative management (eg, percutaneous pinning and/or irrigation and debridement). Available evidence is derived largely from retrospective series and case reports; therefore, recommendations regarding fixation strategy and antibiotic selection should be interpreted in this context. Across studies, early recognition and timely treatment are associated with favorable outcomes, whereas delayed or incomplete management increases the risk of infection, osteomyelitis, malunion, nail deformity, and physeal disturbance. Seymour fractures should be recognized promptly and managed with the same vigilance as other pediatric open fractures. Key Concepts: (1)Seymour fractures are considered open distal phalanx physeal injuries due to direct communication between the fracture and the nail bed or germinal matrix.(2)A Seymour fracture should be presumed in any skeletally immature patient with a mallet-type fingertip deformity, nail fold bleeding, subungual hematoma, or proximal nail plate displacement superficial to the eponychial fold.(3)Dedicated lateral radiographs centered on the involved digit are critical for identifying distal phalanx physeal separation but nondiagnostic imaging does not rule out a Seymour fracture when clinical evidence of nail-unit violation is present.(4)Management should follow open-fracture principles with prompt antibiotics, irrigation and debridement, removal of interposed tissue, anatomic reduction, and selective stabilization when instability persists.