November 14, 2021
Management of toe fractures cover

Management of Toe Fractures

Introduction

Toe fractures represent one of the most commonly encountered fracture patterns in the clinical setting and virtually all of them can be treated without surgery. They represent about 9% of fractures in the primary care setting and 3% of all fractures seen in children.[1] Rennie, Louise, et al. “The epidemiology of fractures in children.” Injury 38.8 (2007): 913-922.. The incidence is estimated between 14 and 39.6 cases per 10,000 people.[2]Fife, Daniel, and Jerome I. Barancik. “Northeastern Ohio trauma study III: incidence of fractures.” Annals of emergency medicine 14.3 (1985): 244-248.[3]Van Vliet-Koppert, Sabine T., et al. “Demographics and functional outcome of toe fractures.” The Journal of foot and ankle surgery 50.3 (2011): 307-310.. The lesser digits are affected much more commonly (~80%) than the great toe (~20%).[4]Fife, Daniel, and Jerome I. Barancik. “Northeastern Ohio trauma study III: incidence of fractures.” Annals of emergency medicine 14.3 (1985): 244-248.

Case Vignette

A 63 year old female presents to your clinic with toe pain after colliding with her night stand the previous evening. On exam, the 5th digit is ecchymotic and swollen. Radiographs reveal a nondisplaced proximal phalanx fracture of the 5th digit. Which of the following treatment options is most appropriate for this patient?

A) Surgical referral
B) Cast and non weight bearing for 6 weeks
C) No treatment indicated
D) Rigid surgical shoe for 4 to 6 weeks

Mechanism of injury is typically from direct trauma such as from striking objects, assault, MVC, fall and sports and recreational activity. Indirect trauma such as hyperflexion or hyperextension can also cause avulsion fractures. The so-called bedroom (i..e nightstand or nightwalker) fracture results from a sudden abduction force applied to the fifth digit against a bedpost while walking in the dark. Stubbed toe can be defined as flexion of the distal phalanx in conjunction with a proximal shearing force which may or may not cause a fracture or subluxation. Associated conditions include nailbed injuries and subungual hematomas.

Image 1. Clinical example of fracture of the 5th toe.

Evaluation

History usually has some clear trauma described by the patient. They will report pain, discomfort with putting shoes on and trouble walking. Bruising and swelling are common and can extend more proximally despite a phalanx fracture. Surprisingly, between 10 and 25% of digital fractures many present without any symptoms, especially the 5th.[5]Venegas, L., J. J. Rainieri, and E. C. Rzonca. “Fracture of the fifth digit. An atypical presentation.” Journal of the American Podiatric Medical Association 85.3 (1995): 166-168.. On exam, inspection can reveal bruising, swelling with deformities being more rare. Be certain to inspect for any areas of open skin suggesting an open fracture. The nail bed should also be closely inspected for injury. Typically, the fractured bone(s) are tender.
Fracture of the distal phalanx of the great toe

Image 2. Fracture of the base of the distal phalanx of the great toe with mild displacement.[6]Case courtesy of Dr Pir Abdul Ahad Aziz Qureshi, Radiopaedia.org, rID: 62584

Image 3. Fracture of the proximal phalanx of the 5th digit with lateral dispalcement.

Standard radiographs are sufficient to make the diagnosis. CT and MRI are not needed unless there is more trauma, concern for stress fracture or other soft tissue injuries.

Management

The vast, vast majority of these patients can be managed without surgery. Most patients will do well initially with PRICE therapy. Immobilization is typically with a rigid surgical shoe which can be augmented by buddy taping or basket weave splinting. Interdigital support such as cotton, lamb’s wool, moldable silicone or felt can prevent maceration. Immobilization typically lasts for 4-6 weeks. In children, you can consider a short leg walking cast with toe plate. Weight bearing status is typically as tolerated but you can consider restricting it in individuals with occupations that include excessive standing, kneeling, or walking. Displaced fractures should be reduced and immobilized. A digital block may help facilitate reduction. Operative potentially indications (a) open fractures, (b) inability to reduce dislocations, (c) displaced intra-articular fractures, (d) unstable displaced fractures, (e) pediatric fractures involving the physis and (f) nondisplaced fractures involving more than 25% of the articular surface.

Image 4. Example of rigid post op or surgical shoe.

Short leg walking cast with toe plate

Image 5. Short leg walking cast with toe plate

Outcomes & Complications

Most patients have good outcomes on the lower extremity AOFAS midfoot score and VAS scoring system. [7]Van Vliet-Koppert, Sabine T., et al. “Demographics and functional outcome of toe fractures.” The Journal of foot and ankle surgery 50.3 (2011): 307-310. This is true whether they are treated surgically or non-surgically. There are no clear return to play guidelines but the athlete should be able to perform sport specific drills on the affected limb before returning to practice or games. Complications are rare but include malunion, nonunion, deformity, decreased range of motion, osteoarthritis and decreased exercise tolerance.

Case Conclusion

Answer is D. The vast majority of phalangeal fractures of the foot, or toe fractures, are non surgical. This is especially true of digits 2-5. In this case, the phalanx fracture is non displaced and there are no surgical indications. The treatment of choice is a rigid surgical shoe for support and protection for around 4 to 6 weeks. No treatment is incorrect and undertreating the injury. Cast and non weight bearing is over treating.

Elleby, D. H., and D. E. Marcinko. “Digital fractures and dislocations. Diagnosis and treatment.” Clinics in podiatry 2.2 (1985): 233-245.

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