Can you write a history and physical examination note for an 8‑year‑old male with an open distal phalangeal (Seymour) fracture of the left index finger?

History and Physical Examination Note: Pediatric Seymour Fracture

CHIEF COMPLAINT

8-year-old male with left index finger injury

HISTORY OF PRESENT ILLNESS

Document the following critical elements:

• Mechanism of injury: Crush injury is most common (63% of cases) 1. Specify exact mechanism (door slam, sports equipment, heavy object).
• Time of injury: Critical for antibiotic timing—infections increase dramatically when antibiotics are delayed beyond 24 hours 1.
• Bleeding at nail fold: Indicates nail bed disruption and confirms open fracture status 2.
• Deformity: Mallet-type flexion deformity at the fingertip 2.
• Previous treatment: Any cleaning, bandaging, or antibiotic administration.
• Tetanus status: Document last tetanus immunization.

PAST MEDICAL HISTORY

• Prior hand injuries
• Immunization status (particularly tetanus)
• Allergies (especially to antibiotics)

PHYSICAL EXAMINATION

Inspection

Key findings that confirm Seymour fracture 2:

• Flexion deformity at DIP joint (mallet-type positioning)
• Bleeding at the nail fold (pathognomonic for open injury)
• Proximal nail plate displacement superficial to the eponychial fold
• Subungual hematoma (if nail plate intact)
• Laceration or skin disruption over dorsal DIP joint

Palpation

• Point tenderness over distal phalanx physis
• Assess for instability with gentle stress
• Evaluate for crepitus

Neurovascular Examination

• Capillary refill of affected digit
• Two-point discrimination (normal <6mm in children)
• Sensation to light touch in radial and ulnar digital nerve distributions
• Perfusion and color of digit

Range of Motion

• Active and passive DIP joint motion (typically limited by pain and deformity)
• Compare to contralateral digit
• Assess PIP and MCP joint motion

Wound Assessment (if present)

• Size and location of laceration
• Contamination level
• Tissue viability

IMAGING

Standard radiographs 3:

• Dedicated lateral view centered on the affected digit (critical for diagnosis) 2, 4
• PA view of the digit
• Oblique view increases diagnostic yield 3

Expected findings:

• Salter-Harris type I or II physeal separation
• Dorsal displacement of distal phalanx
• Note: Equivocal imaging does NOT rule out Seymour fracture when clinical evidence of nail-unit violation is present 2

ASSESSMENT

Open Salter-Harris [type] fracture of left index finger distal phalanx (Seymour fracture)

This is an open fracture due to direct communication between the fracture site and nail bed/germinal matrix 2.

PLAN

Immediate Management

1. Antibiotics within 24 hours of injury (infection rate 6.9% vs 76.5% if delayed) 1

   • First-generation cephalosporin (e.g., cefazolin)
   • Consider adding clindamycin for contaminated wounds 5

2. Tetanus prophylaxis if indicated

3. Surgical intervention following open fracture principles 2, 4:

   • Irrigation and debridement
   • Nail plate removal
   • Removal of interposed germinal matrix or nail bed tissue from fracture site
   • Anatomic reduction
   • Percutaneous K-wire fixation if unstable 2, 4
   • Nail bed repair
   • Splint immobilization

Disposition

• Urgent orthopedic hand surgery consultation (same day)
• NPO for anticipated surgery
• Pain control
• Elevation of affected extremity

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Critical Pitfall: Delayed recognition or treatment increases risk of infection (27.3% overall), osteomyelitis, malunion, nail deformity, and physeal disturbance 2, 1, 6. Maintain high index of suspicion in any skeletally immature patient with DIP flexion deformity and nail fold bleeding 2.