Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Toe Fracture

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.
  • Most common fracture of the forefoot
  • Hallucal or proximal phalanx fractures are seen with stubbing injuries, whereas distal phalanx fractures are seen in crush-type injuries.
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.
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.
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
    • Rest, cryotherapy, and elevation acutely
  • Displaced fractures or dislocated toes:
    • Reduction and appropriate splinting before referral to an orthopaedic surgeon
  • Subungual hematomas can be decompressed with hot sterile needle or electrocautery.
Activity
  • Buddy taping and weightbearing as tolerated in protective or hard-soled shoe
    • Children: 3-4 weeks usually is sufficient.
    • 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 brided and irrigated thoroughly in addition to antibiotic treatment for prevention of osteomyelitis.
  • Open reduction and internal fixation is recommended for displaced, angulated, and intra-articular fractures.
    • In the hallux, screws, pins, and plating may be used.
    • In the lesser toes, Kirschner wires or miniscrews may be appropriate.
Follow-up
Prognosis
The prognosis is good.
Complications
  • Malunion
  • Nonunion
  • Infection/osteomyelitis
  • Nail bed deformity
Patient Monitoring
Serial radiographs are obtained.
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.

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