//fpnotebook.com/
Toe Fracture
Aka: Toe Fracture, Great Toe Fracture, First Toe Fracture, Lesser Toe Fracture, Foot Phalanx Fracture
- Mechanism
- Heavy object dropped on toe (crush injury)
- Stubbed toe
- Epidemiology
- Proximal phalanx most commonly injured (esp. 5th)
- Signs
- Focal pain, swelling and Ecchymosis
- Painful ambulation
- Imaging
- Three view XRay of the affected toe
- Management: Indications for orthopedic referral
- General indications
- Perfusion defect (emergency)
- Open Toe Fracture (suspected or actual)
- Skin necrosis overlying Fracture site
- Great Toe Fracture indications (includes general above)
- First Toe Fracture-dislocation
- Displaced intra-articular Fracture
- Unstable displaced Fractures
- Children with Fracture involving physis
- Nondisplaced intra-articular Fracture >25% of joint
- Lesser Toe Fracture indications (includes general)
- Fracture dislocations
- Displaced intra-articular Fractures
- Children with Salter-Harris Fractures III to V
- Angulation >20 degrees in dorsoplantar plane or rotation, or >10 degrees in mediolateral plane
- Management: Great Toe Fractures
- Reduce displaced Fracture as with Lesser Toe Fractures
- Initial: Immobilization
- Short Leg Walking Cast with toe plate or short leg walking boot for 2-3 weeks
- Continue immobilization if persistent symptoms
- Next: Progress if minimal symptoms
- Buddy taping and rigid-soled shoe for 3-4 weeks
- Start range of motion Exercises at 4 weeks
- Refer for inadequate or unstable reduction
- Follow great toe XRays
- Post-reduction films
- Repeat in 7-10 days (5 days for a child)
- Repeat weekly if unstable or intra-articular Fracture
- Healing course
- Expect 4-6 weeks total
- Athletes may require >8 weeks to return fully to activity
- Management: Non-displaced Lesser Toe Fractures
- Acute management for first 72 hours
- Rest
- Ice Therapy for 20 minutes of each hour
- Elevation
- Splinting 3-6 weeks until non-tender
- Hard soled shoe and
- Buddy taping Fractured toe to adjacent toe
- Use cotton padding between toes and tape together
- Re-tape every 2-3 days
- Follow-up care
- Follow-up in 1-2 weeks and then every 2-4 weeks until fully healed
- Repeat XRay is optional in non-displaced Fractures
- Repeat XRay at 7-10 days for Fractures requiring reduction or more than 25% joint involved
- Work on range of motion until matches opposite toe
- Management: Displaced lesser (2-5) Toe Fractures
- Digital Block to anesthetize affected toe
- Reduce Fracture with longitudinal traction
- Continue manipulation if rotational deformity
- Toe nail should lie in same plan as adjacent toes
- Splint with buddy taping after reduction (see above)
- Refer if reduction not maintained in splint
- Management: Subungual Hematoma
- Decompress with needle or cautery
- Avoid nail removal if possible
- Acts as distal phalanx splint
- Some recommend nail removal for hematoma >50%
- Explore wound and suture Nail Bed Laceration
- Differential Diagnosis
- Sesamoid Fracture (great toe)
- Complications
- Malunion resulting in persistent pain
- Degenerative Joint Disease (intraarticular Fracture)
- Osteomyelitis (open Fractures)
- References
- Marx (2002) Rosen's Emergency Medicine, p. 731
- Simon (2001) Emergency Orthopedics, McGraw, p. 554-7
- Bica (2016) Am Fam Physician 93(3): 183-91 [PubMed]
- Hatch (2003) Am Fam Physician 68:2413-8 [PubMed]