II. Mechanism

  1. Heavy object dropped on toe (crush injury)
  2. Stubbed toe

III. Epidemiology

  1. Proximal phalanx most commonly injured (esp. 5th)

IV. Signs

  1. Focal pain, swelling and Ecchymosis
  2. Painful ambulation

V. Imaging

  1. Three view XRay of the affected toe

VI. Management: Indications for orthopedic referral

  1. General indications
    1. Perfusion defect (emergency)
    2. Open Toe Fracture (suspected or actual)
    3. Skin necrosis overlying Fracture site
  2. Great Toe Fracture indications (includes general above)
    1. First Toe Fracture-dislocation
    2. Displaced intra-articular Fracture
    3. Unstable displaced Fractures
    4. Children with Fracture involving physis
    5. Nondisplaced intra-articular Fracture >25% of joint
  3. Lesser Toe Fracture indications (includes general)
    1. Fracture dislocations
    2. Displaced intra-articular Fractures
    3. Children with Salter-Harris Fractures III to V
    4. Angulation >20 degrees in dorsoplantar plane or rotation, or >10 degrees in mediolateral plane

VII. Management: Great Toe Fractures

  1. Reduce displaced Fracture as with Lesser Toe Fractures
  2. Initial: Immobilization
    1. Short Leg Walking Cast with toe plate or short leg walking boot for 2-3 weeks
    2. Continue immobilization if persistent symptoms
  3. Next: Progress if minimal symptoms
    1. Buddy taping and rigid-soled shoe for 3-4 weeks
    2. Start range of motion Exercises at 4 weeks
  4. Refer for inadequate or unstable reduction
  5. Follow great toe XRays
    1. Post-reduction films
    2. Repeat in 7-10 days (5 days for a child)
    3. Repeat weekly if unstable or intra-articular Fracture
  6. Healing course
    1. Expect 4-6 weeks total
    2. Athletes may require >8 weeks to return fully to activity

VIII. Management: Non-displaced Lesser Toe Fractures

  1. Acute management for first 72 hours
    1. Rest
    2. Ice Therapy for 20 minutes of each hour
    3. Elevation
  2. Splinting 3-6 weeks until non-tender
    1. Hard soled shoe and
    2. Buddy taping Fractured toe to adjacent toe
      1. Use cotton padding between toes and tape together
      2. Re-tape every 2-3 days
  3. Follow-up care
    1. Follow-up in 1-2 weeks and then every 2-4 weeks until fully healed
    2. Repeat XRay is optional in non-displaced Fractures
      1. Repeat XRay at 7-10 days for Fractures requiring reduction or more than 25% joint involved
    3. Work on range of motion until matches opposite toe

IX. Management: Displaced lesser (2-5) Toe Fractures

  1. Digital Block to anesthetize affected toe
  2. Reduce Fracture with longitudinal traction
  3. Continue manipulation if rotational deformity
    1. Toe nail should lie in same plan as adjacent toes
  4. Splint with buddy taping after reduction (see above)
  5. Refer if reduction not maintained in splint

X. Management: Subungual Hematoma

  1. Decompress with needle or cautery
  2. Avoid nail removal if possible
    1. Acts as distal phalanx splint
    2. Some recommend nail removal for Hematoma >50%
      1. Explore wound and suture Nail Bed Laceration

XI. Differential Diagnosis

  1. Sesamoid Fracture (great toe)

XII. Complications

  1. Malunion resulting in persistent pain
  2. Degenerative Joint Disease (intraarticular Fracture)
  3. Osteomyelitis (open Fractures)

XIII. References

  1. Marx (2002) Rosen's Emergency Medicine, p. 731
  2. Simon (2001) Emergency Orthopedics, McGraw, p. 554-7
  3. Bica (2016) Am Fam Physician 93(3): 183-91 [PubMed]
  4. Hatch (2003) Am Fam Physician 68:2413-8 [PubMed]

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