Toe Fracture

By admin Last updated Mar 15, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Toe Fracture

Toe Fracture

Mark Clough MD

Basics

Description

Fracture of the proximal, middle, or distal phalanx:
- The hallux, or great toe, has 2 phalanges.
- The 2nd–5th toes each have 3 phalanges (1).
Most common fracture of the forefoot (2)
Hallucal or proximal phalanx fractures
are seen with stubbing injuries, whereas distal phalanx fractures are
seen in crush-type injuries (2).

Pediatric Considerations

Often Salter-Harris injury of phalangeal growth plate
Often a benign injury with good prognosis
In rare cases of severe displacement or angulation, operative reduction may be indicated.

General Prevention

Protective shoe wear, such as steel-toed shoes, should be worn as appropriate.

Epidemiology

Incidence

Incidence is 140 per 100,000 population per year, and the Male:Female ratio is 1:6 (3).

Risk Factors

Heavy construction work
Improper protective foot wear or walking barefoot
Ambulating at night in the dark without proper footwear

Etiology

The mechanism of injury is usually in the form of direct trauma (a stubbing or crushing injury).
The lesser toes are subject to abduction injuries such as the “night walker fracture” (3).

Diagnosis

Signs and Symptoms

Pain
Swelling
Ecchymosis
Painful weightbearing
Difficult ROM ambulation
Difficulty with donning shoe wear

Physical Exam

Tenderness to palpation
Swelling and ecchymosis
Limited ROM
Angulation or deformity
Subungual hematoma with crush injury of toe

Tests

Imaging

AP, lateral, and oblique radiographs of the toe (not foot) identify the fracture and help dictate necessary treatment.

Differential Diagnosis

Contusion
DIP joint sprain
PIP joint sprain
Joint dislocation

Treatment

General Measures

Closed, nondisplaced fractures:
- Buddy taping immobilization and a rigid-soled shoe for help with ambulation/protection (3)
- Rest, cryotherapy, and elevation acutely
Displaced fractures or dislocated toes:
- Reduction and appropriate splinting before referral to an orthopaedic surgeon (2)
Subungual hematomas can be decompressed with hot sterile needle or electrocautery (2).

Activity

Buddy taping and weightbearing as tolerated in protective or hard-soled shoe
- Children: 3–4 weeks usually is sufficient (3).
- Adults: 4–6 weeks may be necessary.
Swelling of toe and difficulty with tight-fitting shoe wear may last 2–3 months after fracture.

Special Therapy

Physical Therapy

Not generally applicable or necessary

Medication

NSAIDs
Analgesics

P.465

Surgery

Open fractures should be débrided and irrigated thoroughly in addition to antibiotic treatment for prevention of osteomyelitis (4).
Open reduction and internal fixation is recommended for displaced, angulated, and intra-articular fractures.
- In the hallux, screws, pins, and plating may be used (3).
- In the lesser toes, Kirschner wires or miniscrews may be appropriate (3).

Follow-up

Prognosis

The prognosis is good.

Complications

Malunion
Nonunion
Infection/osteomyelitis
Nail bed deformity (3)

Patient Monitoring

Serial radiographs are obtained.

References

1. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician 2003;68:2413–2418.

2. Armagan OE, Shereff MJ. Injuries to the toes and metatarsals. Orthop Clin North Am 2001;32:1–10.

3. Mittlmeier T, Haar P. Sesamoid and toe fractures. Injury 2004;35:S-B87–S-B97.

4. Ribbans WJ, Natarajan R, Alavala S. Pediatric foot fractures. Clin Orthop Relat Res 2005;432: 107–115.

Additional Reading

Sanders R. Fractures of the midfoot and forefoot. In: Coughlin M, Mann R, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis: Mosby, 1999:1574–1605.

Thordarson DB. Fractures of the midfoot and forefoot. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders, 2000: 1265–1296.

Miscellaneous

Codes

ICD9-CM

826.0 Fracture of the phalanx

Patient Teaching

Patients should be told to protect the injured foot with a rigid-soled shoe.
Pain and swelling should be expected to last several weeks to months after successful fracture healing.

Activity

Typically, weightbearing as tolerated in hard-soled surgical postoperative shoe

FAQ

Q: What are 2 common mechanisms of injury producing toe fractures?

A: Jamming/stubbing trauma and crush injury.

Q: What types of toe fractures typically require surgical treatment?

A:
Open fractures require débridement, whereas displaced, angulated, or
intra-articular fractures should be reduced and stabilized.