Toe Fracture

Aka: Toe Fracture, Great Toe Fracture, First Toe Fracture, Lesser Toe Fracture

1. Mechanism
   1. Heavy object dropped on toe
   2. Stubbed toe
2. Epidemiology
   1. Proximal phalanx most commonly injured (esp. 5th)
3. 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. Management: Non-displaced 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. Repeat XRay is optional in non-displaced Fractures
      2. Work-on range of motion until matches opposite toe
5. 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
6. Management: Displaced Great Toe Fractures
   1. Reduce Fracture as with Lesser Toe Fractures
   2. Splint as with less Toe Fracture as above
   3. Refer for inadequate or unstable reduction
   4. 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
7. 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 SutureNail Bed Laceration
8. Differential Diagnosis
   1. Sesamoid Fracture (great toe)
9. Complications
   1. Malunion resulting in persistent pain
   2. Degenerative Joint Disease (intraarticular Fracture)
   3. Osteomyelitis (open Fractures)
10. References
    1. Marx (2002) Rosen's Emergency Medicine, p. 731
    2. Simon (2001) Emergency Orthopedics, McGraw, p. 554-7
    3. Hatch (2003) Am Fam Physician 68:2413-8