Gavin H. Harris MD, Emory University, Department of Medicine, Divisions of Critical Care Medicine & Infectious Diseases, Emory University School of Medicine, Atlanta, GA
Case Report
History:
A 32-year-old otherwise healthy, former Division I swimmer was surfing a longboard in 2-3 foot fickle East Coast waves. After one ride he was caught inside near shore in approximately 2-3ft of water and pulled his board in close to keep from flying out and striking other surfers. As the wave crested and broke, he grasped the leash with his right hand close to the leash-plug and the leash twisted and snapped to tension when he ducked under the lip. The surfer immediately felt a shooting pain in his right fifth digit and saw blood in the water. He quickly exited the water and called one of his friends for help. Upon inspection from the other surfer, a physician, the distal phalanx of the R fifth digit had pierced the skin at the location of the distal interphalangeal joint, rupturing the nail bed. Given the amount of blood there was concern for vascular injury. The wound was quickly irrigated with fresh water from a water bottle. Sensation was intact throughout the finger except for the fingertip. A clean towel was then placed around the finger and hand and the surfer was walked down the beach to the lifeguard shack where an ambulance arrived and transported the patient to the local hospital.
Past Medical/Family/Social History:
The patient had a past medical history of chronic osteoarthritis in his bilateral shoulders and sacroiliac joint along with a bulging disk at L4, but had no prior history of surgeries and no allergies to medications. He did not take illicit substances nor smoke tobacco.
Physical Exam:
Vital signs were stable on arrival to the emergency department, the patient was in no acute distress, alert, oriented though pale-appearing. Musculoskeletal exam notable for an open displaced fracture of the distal phalanx of the fifth digit with exposed subcutaneous tissue and active bleed. Capillary refill was sluggish and sensation on the distal tip of the finger was diminished.
Hospital Course:
An X-ray was performed, localizing and confirming the fracture as the sole injury sustained (Figure 1). A wider incision was then created on the patient’s finger to re-insert the bone and perform open reduction and splinting by orthopedic surgery. The patient was discharged from the emergency department the same day on oral antibiotics given his exposure to seawater.
Three weeks later he returned to have an outpatient pinning procedure to keep his finger in proper alignment for 6 weeks. Following removal, the patient reported he regained 90% mobility after 3-4 months, and after one year had near-complete recovery. He has since returned to surfing.
Discussion
It is estimated that fractures in surfing account for <12% of injuries. A Seymour fracture – the injury the patient sustained – first described in 1966, is a type of mallet finger injury that has an associated nail bed injury often along with ungual subluxation. In fact, this occurs not just in surfing but can result from a variety of mechanisms, the most common of which include crush injuries, hyperflexion events and falls. The distal phalanx of a fully extended digit undergoes forceful flexion or a crush injury occurs as in a closing door, resulting in the injury (Figure. 2). More commonly found in pediatric patients, the true incidence is unknown. While they are uncommon fractures, they are at high risk for complications and can cause significant morbidity. Late presentations increase the risk for infection, growth arrest (in pediatric patients) and persistent deformity. In the case described, the time from injury to evaluation in the emergency department was approximately forty-five minutes.
Moderate controversy exists over management. The longstanding approach for open injuries has been surgical intervention to explore fracture sites to obtain anatomical alignment and to minimize risk for osteomyelitis. As most injuries occur in children, this necessitates the use of the operating room where appropriate examination, irrigation and debridement can be completed. The nail must be lifted to obtain an appropriate view. Reduction by manipulation can be achieved by applying pressure to extend the distal fragment while applying counterpressure onto the dorsal aspect of the proximal fragment. Reduction must be completed without a step-off to avoid nailbed injury.
Our patient, as an alternative, had a two-stage procedure – reduction as above, followed by a stabilizing Kirschner wire (K-wire). This is introduced longitudinally through the distal phalanx and advanced through the fracture site. The distal portion of the wire is left visible outside to facilitate removal, usually 6 weeks post operatively. Another approach has been to manage all cases in the emergency department without the need for general anesthesia, though close follow up is required. In the immediate post-injury time, prophylactic antibiotics are prescribed for 5-7 days, with appropriate coverage tied to water exposure risk of the patient.
As surfers we all need to be aware of our surroundings, equipment, and abilities. Injuries can happen in even the smallest of surf, in the gentlest of conditions, and we can never let our guard down. This fracture is one of the reasons why surfers are taught never to grab the leash. In bigger surf the risk of finger amputation is higher.
Email: gavin.harris@emory.edu
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