Community EM

Do You 'See More' Fractures? Don’t Overlook 'Seymour' Fractures!

Co-Authors: Dr. Madalene Boyle and Dr. Andrew Beck

Case 1

A 10-year-old male presents to the ED with his parents after his finger was slammed in a car door. His parents are concerned that it’s bleeding and appears deformed. The incident occurred 30 minutes prior to presentation. His parents state that there was “a lot of bleeding.” His past medical history is notable for asthma, and there is no history of fragility fractures, connective tissue disorders, or bleeding diatheses. Physical exam reveals the injury as shown. Flexion of the digit is preserved and extension is limited due to pain and deformity. Neurovascular exam is intact. 

 Car door injury to 5th digit.

Car door injury to 5th digit.

Screen Shot 2018-08-24 at 11.41.07 AM.png

An x-ray was taken to assess for fracture and/or foreign body. The original film was unavailable, but an illustrative lateral view is shown(3). No foreign body was noted, but a characteristic injury pattern was observed.


 

Case 2

A 14-year old right-handed football player presents to the community Emergency Department with a right middle finger deformity. Patient was playing football when he went to make a tackle and his finger was crushed beneath another player.  

Screen Shot 2018-08-24 at 11.45.28 AM.png

On exam, his middle finger has dried blood at the base of the nail. The proximal nail appears partially avulsed. His finger appears flexed at the DIP although he is able to fire his extensors/flexors at the DIP.  He has no sensory deficits. 

 Image from Azburg, 2013.

Image from Azburg, 2013.

 

The Seymour Fracture

Definition & Epidemiology(1,2): Originally described in 1966 by Seymour, the eponymous Seymour fracture is defined as an open, displaced distal phalangeal fracture with associated nail bed injury. This injury can easily be overlooked as minor trauma to the nail which can have consequences for infection and growth arrest, leading to chronic deformity and loss of function.1 20-30% of phalangeal fractures in children involve the physis, and the long finger is most commonly affected. The mechanism is typically a crush injury in a door. These are Salter-Harris Type 1 or 2 fractures and the nailbed injury is commonly a laceration or plate avulsion. Often, interposition of soft tissue at the fracture site impedes bedside reduction. 

The Seymour fracture will often resemble a mallet finger. For this reason, any pediatric patient with an apparent mallet finger deformity and blood at the nail fold should be evaluated seriously for this fracture. The mallet finger appearance occurs because of an imbalance between the flexor and extensor tendons.  The extensor tendon inserts at the epiphysis of the distal phalanx. The flexor digitorum profundus inserts at the metaphysis.  There is no actual injury to the extensor tendon (as in Mallet finger). The imbalance is created through the physis or fracture site (see image). 


Diagnosis (1,2,3): Physical exam demonstrates a flexed dorsal interphalangeal joint, ecchymosis, swelling, and mallet deformity. The nail plate lies superficial to the eponychial fold which will give the appearance of a longer-than-normal nail.1,2,3 Imaging reveals a fracture through the physis along with other potential fractures. The AP radiographic view may be normal since lateral deviation is not commonly seen. The lateral view is more sensitive and will show a widened physis, displacement, and angulation. It is important not to confuse the presentation for a mallet finger which is the key differential diagnosis. Mallet fractures involve the joint while the Seymour fracture is isolated to the growth plate without epiphyseal displacement. 

...any pediatric patient with an apparent mallet finger deformity and blood at the nail fold should be evaluated seriously for this fracture.


Risks: A Seymour fracture has many associated complications. Based on fracture location, the germinal matrix (responsible for nail production) can become entrapped in the fracture site (See image above). This prevents a simple reduction of the fracture. Additionally, damage to the germinal matrix can cause a permanent nail plate deformity.  If soft tissue becomes incarcerated in the physis, it can cause growth arrest and finger length discrepancy. Importantly, failure to treat Seymour fractures as open fractures can result in infection and even chronic osteomyelitis. 


Management: These are open fractures.  In the ER, it is appropriate to give a dose of parenteral antibiotics. A first generation cephalosporin such as Cefazolin is suitable. Patients should be treated with a short (5-7 day course) of oral antibiotics upon discharge. 
A hand specialist should manage Seymour fractures. Appropriate treatment of Seymour fracture consists of removal of the nail plate, exploration of the fracture site (to ensure no tissue entrapment), thorough irrigation and debridement, and reduction. For unstable fractures, a K-wire through the fracture and DIP is sometimes necessary to maintain this reduction.  The nail bed laceration should be repaired. The nail should be replaced or stented with suture packaging material. 
Younger patients may require anesthesia and an operating room for exploration and adequate treatment. Older patients may be able to have treatment within the department with adequate pain control and local nerve blocks. 
Appropriate management of Seymour Fractures is crucial. A recent review by Reyes (2017) evaluated management and associated complications of Seymour fractures.  There was a much higher rate of infection (both superficial and osteomyelitis) in those patients who do not receive proper treatment.  Emergency Medicine providers must be able to recognize this injury in order to initiate antibiotics and facilitate appropriate consultation with a hand specialist. 

Prognosis (3): As mentioned above, nonoperative management may be possible for minimally displaced Seymour fractures. However, by definition, Seymour fractures are open and displaced, and the majority of these injuries require open reduction and fixation. Functional and cosmetic outcomes at two years are equivalent between operative and nonoperative groups when selected for treatment based on degree of displacement. Major complications include reduced range of motion, nail dystrophy, and digit length discrepancy, all of which can have major functional consequences especially if involving the 2nd or 3rd digits on the dominant hand, or if the patient requires the use of multiple digits for a profession (pianist, artist, and typist). 


Case 1 Resolution

This patient received a bedside nail bed repair with avulsion and replacement of the nail plate, then reduction via hyperflexion followed by traction and extension. The patient was splinted and received operative repair within one week of the injury. 


Case 2 resolution

A hand team was not available at the community hospital. Patient was transferred to the Children’s Hospital where he was treated by the hand team.  He underwent I+D in the ER and reduction/repair. He has since had an uneventful follow-up appointment. 

 

References
1)    Nellans KW, Chung KC. Pediatric Hand Fractures. Hand Clin. 2013 Nov; 29(4): 569–578. doi:  10.1016/j.hcl.2013.08.009. 
2)    Watts E. Seymour Fracture. https://www.orthobullets.com/hand/6000/seymour-fracture# Accessed 11/27/2017.
3)    Krusche-Mandl I, Kottstorfer J, Thalhammer G et. Al. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am. 2013 Feb;38(2):258-64. doi: 10.1016/j.jhsa.2012.11.015.
4)    Abzug JM, Kozin SH. Seymour fractures. J Hand Surg Am. 2013;38:2267–2270. 
5)    Reyes BA, Ho CA.  The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration. J Pediatr Orthop. 2017: 37: 247-253. 
6)    Kattan AE, AlShomer F, Alhujayri AK, Alfowzan M, Murrad KA, Alsajjan H. A case series of pediatric seymour fractures related to hoverboards: Increasing trend with changing lifestyle. International Journal of Surgery Case Reports. 2017: 38: 57-60. 

 

FACULTY REVIEWER/EDITOR: Dr. Kristina McAteer


 

Hiding in Plain Sight: Unexpected Findings on Chest X-Ray

Rich Gorilla CT.jpg

Notice anything unusual about this scan? In a study by Melissa Trafton Drew and Jeremy Wolfe, 83% of radiologists didn't notice the gorilla in the top right portion of this image when scrolling through five chest CT scans looking for lung nodules. (1) This is thought to be due to a phenomenon known as inattention blindness. When engaged in a demanding task, we may fail to perceive an unexpected stimulus that is in plain sight. If you don’t believe me, check this out:

The chest x-ray is one of the most commonly performed imaging tests. As emergency medicine physicians, we order chest x-rays to evaluate patients with a wide variety of complaints. Often times, it is our responsibility to interpret the x-ray and create a management plan before a radiologist has a chance to look at the image. This is true in community hospitals without radiologists available during night or weekend hours, in critically ill patients, or in trauma victims at large academic centers. Several studies have shown a discrepancy between the x-ray readings of emergency medicine physicians verses radiologists. (2,3,4,5) There is wide variability in the rate of misinterpretations reported, depending on the type of imaging, the experience level of the clinician, and the difficulty level of the chest x-ray findings, among other factors.

Chest x-ray interpretation is a vital skill as interpretation errors can have significant consequences.  False negatives may result in missing life-threatening conditions and worse patient outcomes. False positives may result in further testing, longer ED course and unnecessary interventions.  We are taught to be systematic in our approach to reading an image. However, it is not uncommon to zero in on the part of the chest x-ray we are interested in and unintentionally brush over the rest of the picture. This can lead to missed diagnoses and poorer patient outcomes.

With the importance of accurate chest x-ray interpretation skills in mind, let’s take a step back and review the basics:

The ABC's of Reading a Chest X-ray: 

First- check the patient information, the projection (AP or PA), the date it was taken. Review the aspects that affect the quality of the film.

  • Check the alignment (medial ends of clavicle equidistant from spinous process)
  • Check the inspiratory effort (10-11 posterior ribs in each lung field)
  • Exposure (is the image too bright or too dark? The vertebrae should be visible behind the heart)

Remember the pneumonic “RIPE” to evaluate the quality of an image - Rotation, Inspiration, Projection, Exposure. 

 https://commons.wikimedia.org/wiki/File:Mediastinal_structures_on_chest_X-ray.svg#/media/File:Mediastinal_structures_on_chest_X-ray,_annotated.jpg

https://commons.wikimedia.org/wiki/File:Mediastinal_structures_on_chest_X-ray.svg#/media/File:Mediastinal_structures_on_chest_X-ray,_annotated.jpg

When ready to review the x-ray, consider the commonly used “A, B, C, D, E, F” system.

A - Airway- trachea, carina, right and left main bronchi

B - Bones and soft tissue- clavicles, ribs- posterior rand anterior, vertebral bodies, and sternum on lateral films. Look for any fractures, dislocations, or lytic lesions.

C - Cardiac- cardiac silhouette and mediastinum. The cardiac silhouette should be less than half of the thoracic cavity. AP films exaggerate heart size, so this rule does not apply. Assess the borders of the heart and the hilar structures

D - Diaphragm- right should be higher than left and you should see a gastric air bubble on the left. Is there any free air under the diaphragm? Evaluate the costophrenic angle and pleura (normally invisible due to thinness).

E - Everything else (lines and tubes, pacemakers, artificial valves)

F - Fields- FINALLY, evaluate the lung fields. Lungs are the area of greatest interest, so it is helpful to keep this at the end to prevent distraction. Divide each lung into three “zones” when reading a chest x-ray. These do not correlate with the lobes. Remember, there are 2 lobes on the left (upper and lower) and 3 on the right (upper, middle and lower). 

 https://upload.wikimedia.org/wikipedia/commons/thumb/7/7e/2312_Gross_Anatomy_of_the_Lungs.jpg/1280px-2312_Gross_Anatomy_of_the_Lungs.jpg

https://upload.wikimedia.org/wikipedia/commons/thumb/7/7e/2312_Gross_Anatomy_of_the_Lungs.jpg/1280px-2312_Gross_Anatomy_of_the_Lungs.jpg

There are several things that do not fit perfectly into the A-E categories.

  • Apices
    • Look again at the lung above the clavicles
  • Retrocardiac space
    • Look for consolidation or a mass in this region
  • Below the diaphragm
    • Remember that the lungs extend below the diaphragm posteriorly. Look out for consolidation or lesions on the lateral film.
  • Soft-tissue abnormalities
    • Don’t forget to look for air, foreign bodies, and other soft tissue abnormalities.

Now that we have refreshed your memory, it’s time to practice! Imagine that you are in a small community setting, working the overnight shift. There are no radiologists available until the morning and it is up to you to read the chest x-ray.

Go through the examples below and see what findings you can pick up on these chest x-rays.


Case 1: Find the abnormality.

Case 1 answer: This patient has pneumomediastinum. Air appears as curvilinear lucencies outlining the mediastinum. Note the continuous diaphragm sign- the entire diaphragm is visualized as air in the mediastinum separates the heart and the superior surface of the diaphragm.

Case 2: Find the abnormality

Case 2 answer: This patient has a left shoulder dislocation. The humeral head is displaced from the glenoid of the scapula.

Case 3: Find the abnormality

Case 3 answer: This patient has a right middle lobe collapse. This is easier to visualize on the lateral view, where a triangular opacity overlying the cardiac silhouette can be seen. It can be difficult to see a middle lobe collapse on frontal projections. You may notice that the horizontal fissure is no longer visible or that there is blurring of the right heart border. (6)

For more information, check out https://radiopaedia.org/articles/right-middle-lobe-collapse


Case 4: Find the abnormality 

Case 4 answer: The central line placed in the right neck soft tissue crosses the midline. This line was placed in the carotid artery.
 https://pbs.twimg.com/media/CmVRNRzVIAQCaf9.jpg

https://pbs.twimg.com/media/CmVRNRzVIAQCaf9.jpg


Case 5: Find the abnormality

Case 5 answer: Misplaced tooth. Notice the ovoid, radiopaque foreign body in the right mainstem bronchus.

Case 6: Find the abnormality

Case 6 answer: This patient has a left lower lobe pneumonia. There is a positive spine sign on the lateral projection. The spine normally becomes more radiolucent as you progress inferiorly given the increased amount of air containing lung overlying the spine as you travel downwards. Where there is fluid, a mass, or a consolidation in the lower lung fields, the vertebral bodies appear more radiodense.  

For more information, check out http://learningradiology.com/notes/chestnotes/spinesign.htm and https://radiopaedia.org/cases/left-lower-lobe-pneumonia-10


Case 7: Find the abnormality

https://images.radiopaedia.org/images/627328/6743f24a87021f15266d7385963870_big_gallery.jpg

https://images.radiopaedia.org/images/627329/afc5beac8649e5e1fed60df4863281_big_gallery.jpg

Case 7 answer: This patient has Chilaiditi syndrome. In this syndrome, the colon is positioned between the liver and the diaphragm which can appear as free air under the diaphragm. Notice the rugal folds, this helps differentiate bowel containing gas from free air.

For more information, check out: https://radiopaedia.org/articles/chilaiditi-syndrome

Another example of Chilaiditi Syndrome:

 https://upload.wikimedia.org/wikipedia/commons/6/6c/Chilaiditi_obvious.jpg

https://upload.wikimedia.org/wikipedia/commons/6/6c/Chilaiditi_obvious.jpg

Here is an example of actual pneumperitonium:

 https://upload.wikimedia.org/wikipedia/commons/3/3c/Pneumoperitoneum_modification.jpg

https://upload.wikimedia.org/wikipedia/commons/3/3c/Pneumoperitoneum_modification.jpg


Case 8: Find the abnormality.

https://upload.wikimedia.org/wikipedia/commons/thumb/9/98/Pneumothorax_im_liegen.jpg/689px-Pneumothorax_im_liegen.jpg

Case 8 answer: This patient has a left pneumothorax. This patient is supine at the time of this image (like many of our back-boarded and collared trauma patients). Notice the abnormally deep costophrenic angle on the left. This is known as the deep sulcus sign and is present because air collects in the non-dependent potions of the pleural space (anteriorly and basally when the patient is supine, apex when the patient is upright).

Case 9: Find the abnormality:

http://image.wikifoundry.com/image/1/UyT1bPAhr9Ui2Q1JlkLj_w115368/GW500H488

Case 9 Answer: This x-ray is NORMAL. It looks like this patient has a left pneumothorax on first glance, but the pleural line you think you see is actually a skin fold. (7) Notice that the pulmonary vessels extend to the outer edge of the lung fields.

For more information, check out: http://www.wikiradiography.net/page/Patterns+of+Misdiagnosis+in+Plain+Film+Radiography section 16 on artifacts.


Case 10: Find the Abnormality.

Case 10 Answer: The OGT is malpositioned and is entering the right mainstem bronchus and terminating in the right lung.

Case 11: Find the Abnormality.

https://radiopaedia.org/cases/scapular-fracture-11

Case 11 Answers: There is a comminuted fracture through the body of the right scapula. Fractures of the scapula usually occur in association with injuries to the ipsilateral lung, thoracic cage and shoulder girdle. Presence of a scapula fracture mandates further investigation for associated injuries. (8)

Case 12: Find the abnormality.

Case 12 Answer: This patient has extensive pneumomediastinum extending cranially into the neck. There is extensive soft tissue emphysema about the chest wall. This occurred after a coughing fit (believe it or not). No evidence of pneumonia or pneumothorax is seen, although it is difficult to visualize the lung fields with the overlying subcutaneous emphysema.

Conclusion

Chest x-ray interpretation is a vital skill as errors can lead to missed diagnoses and worse patient outcomes. Adopt a systemic approach to reading a chest x-ray and use it every single time. Use the ABCDEF pneumonic to guide your interpretation and to avoid overlooking an abnormality that are hiding in plain sight.

Faculty Reviewer: Robert Tubbs, MD

References

  1. Drew T, Vo ML, Wolfe JM. The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol Sci 2013;24:1848-53.
  2. Petinaux B, Bhat R, Boniface K, Aristizabal J. Accuracy of radiographic readings in the emergency department. Am J Emerg Med 2011;29:18-25.
  3. Safari S, Baratloo A, Negida AS, Sanei Taheri M, Hashemi B, Hosseini Selkisari S. Comparing the interpretation of traumatic chest x-ray by emergency medicine specialists and radiologists. Arch Trauma Res 2014;3:e22189.
  4. Soudack M, Raviv-Zilka L, Ben-Shlush A, Jacobson JM, Benacon M, Augarten A. Who should be reading chest radiographs in the pediatric emergency department? Pediatr Emerg Care 2012;28:1052-4.
  5. Nitowski LA, O'Connor RE, Reese CLt. The rate of clinically significant plain radiograph misinterpretation by faculty in an emergency medicine residency program. Acad Emerg Med 1996;3:782-9.
  6. Right Middle Lobe Collapse. at https://radiopaedia.org/articles/right-middle-lobe-collapse.)
  7. Patterns of Misdiagnosis in Plain Film Radiography. at http://www.wikiradiography.net/page/Patterns+of+Misdiagnosis+in+Plain+Film+Radiography.)
  8. Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma 2008;65:430-5.

Thumb’s Up for Diagnosing and Managing UCL Injuries

Case

32 year old right handed man presents with right thumb pain after a mechanical fall from standing onto steps.  While falling, his outstretched thumb caught on a step.  He denies other injury.  On exam, he has pain and swelling at the thumb MCP joint.  There is a palpable lump on the ulnar side of the base of his thumb.  He has full ROM and intact strength in the affected digit.

What are the next steps in this patient’s management?

Epidemiology

  • Most commonly occur in athletes when a force causes thumb abduction
  • Skiing accidents in which the thumb is abutted against a fixed pole are the prototypical injury
  • More common in males with a ratio of 3:2
  • Complete ulnar collateral ligament tears can occur by non-sport related falls, motor vehicle crashes in which the hands are on the steering wheel, or bicycle injuries from handlebars

UCL anatomy

  • Runs from middle of metacarpal head to the volar aspect of the proximal phalanx
  • Provides structural strength to the thumb
  • Resists valgus load to thumb

Mechanism of Injury

  • Hyper-extension or abduction of the thumb causes the UCL to avulse from the proximal    phalanx
  • Acute injuries result in a complete or partial tear of the ligament
  • Avulsion fractures of proximal phalanx may or may not be present

Clinical Presentation

  • Acute injuries present with pain and swelling of the base of the thumb
  • Chronic injuries, also known as Gamekeeper’s thumb, present with loss of strength of the   thumb and deformity

Traditionally, this injury was originally described in people who manually and repetitively sacrificed small game by breaking the animal’s neck.

Unknown.jpeg

Exam

  • Cornerstone of diagnosis
  • Goal of exam is to evaluate joint stability
  • Valgus stress of the MCP joint reveals increased laxity
  • Test in both neutral position and with MCP joint fully flexed.  Fully flexing the joint isolates the UCL from the volar plate, which can provide additional stability
  • Angulation of >35 degrees, or a difference of >15 degrees between hands signifies a        positive test.
  • In partial tears, the loss of a distinct endpoint while stressing may be noted

Stener lesion

Occurs when the proximal end of the completely torn ligament is pulled from its normal location deep to the abductor aponeurosis and then fails to reduce itself properly, remaining superficial to the aponeurosis   

  • Present in up to 50% of complete UCL tears.
  • Exam may note a palpable lump
  • Surgical intervention is required
  • Stressing the MCP has NOT been shown to cause a Stener lesion where one did not already exist.
  • Pinch grip may be reduced in both acute and chronic injuries

ED Evaluation

  • Plain films to evaluate for avulsion fracture of proximal phalanx
  • Stener lesion will not be evident of plain films
  • Ultrasound has not been fully validated in diagnosis UCL tears
  • MRI is not cost effective in the ED, but may be obtained in follow-up in consultation with a hand surgeon

ED Management

  • Thumb spica is hallmark of ED management, allowing for immobilization of thumb MCP joint
  • If joint deemed unstable, follow-up within 1 week to a hand surgeon is advised to allow for surgical planning.  A delay in surgery can cause contracture of the UCL and increases  likelihood of chronic instability
  • For stable injuries, non-urgent follow-up within 4 weeks is recommended.

Faculty Reviewer: Dr. Kristina McAteer

References

  • Germano, T.  Falls on the Out-Stretched Hand and Other Traumatic Injuries of the Hand and Wrist: Part II.  Emergency Medicine Reports:  The Practical Journal for Emergency Physicians.  Volume 28, Number 18.  August 20, 2007.
  • Gammons, M et al.  Ulnar collateral ligament injury (gamekeeper's or skier's thumb).  Retrieved from UpToDate.com.  Accessed 4/21/2018.
  • Richard, JR.  Gamekeeper’s Thumb:  Ulnar Collateral Ligament Injury.  Am Fam Physician.  19