rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. (OBQ12.89)
Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. ClinPediatr (Phila), 2011. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Initial follow-up should occur within one to two weeks, then every two to four weeks for a total healing time of four to six weeks.6,23,24 Radiographic follow-up in seven to 10 days is necessary for fractures that required reduction or that involve more than 25% of the joint.6, Indications for referral of toe fractures include a fracture-dislocation, displaced intra-articular fractures, nondisplaced intra-articular fractures involving more than 25% of the joint, and physis (growth plate) fractures. Magnetic Resonance Imaging (MRI) scans. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. 36(1)p. 60-3. Surgery is not often required. Copyright 2023 Lineage Medical, Inc. All rights reserved. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). J AmAcad Orthop Surg, 2001. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Joint hyperextension and stress fractures are less common. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). A fractured toe may become swollen, tender, and discolored. A 55 year-old woman comes to you with 2 months of right foot pain. For several days, it may be painful to bear weight on your injured toe. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. fractures of the head of the proximal phalanx. The "V" sign (arrow) indicates dorsal instability. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Bony deformity is often subtle or absent. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. In many cases, a stress fracture cannot be seen until several weeks later when it has actually started to heal, and a type of healing bone called callus appears around the fracture site. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. (SBQ17SE.3)
Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. The proximal phalanx is the toe bone that is closest to the metatarsals. Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. Epub 2017 Oct 1. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Injury. Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensation an indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. 118(2): p. e273-8. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. Because it is the longest of the toe bones, it is the most likely to fracture. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction.
She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures.
Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. (OBQ18.111)
Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). Healing time is typically four to six weeks. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. On exam, he is neurovascularly intact. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Your doctor will tell you when it is safe to resume activities and return to sports. At the first follow-up visit, radiography should be performed to assure fracture stability. The pull of these muscles occasionally exacerbates fracture displacement. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! Copyright 2016 by the American Academy of Family Physicians. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. The collateral ligaments and volar plate at the metacarpophalangeal (MCP) joint stabilize the proximal portion and the extensor tendon pulls the distal fragment into extension. During this time, it may be helpful to wear a wider than normal shoe. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Am Fam Physician, 2003.
Toe fractures are one of the most common fractures diagnosed by primary care physicians. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Most broken toes can be treated without surgery. In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Healing of a broken toe may take 6 to 8 weeks. The localized tenderness of a contusion may mimic the point tenderness of a fracture. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. 2017 Oct 01;:1558944717735947. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Patients with Jones fractures should be referred if there is more than 2 mm of displacement, if conservative therapy is ineffective after 12 weeks of immobilization and radiography reveals nonunion, or if the patient is an athlete or is highly active.2,13,2022, Toe fractures are the most common fractures of the foot.23,24 Most fractures involve minimal displacement and are treated nonsurgically. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Thank you. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). myAO. J Pediatr Orthop, 2001. MB BULLETS Step 1 For 1st and 2nd Year Med Students. laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, Indications. Differential Diagnosis The same mechanisms that produce toe fractures. Because it is the longest of the toe bones, it is the most likely to fracture. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. The fractures reviewed in this article are summarized in Table 1. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. If you experience any pain, however, you should stop your activity and notify your doctor. A proximal phalanx is a bone just above and below the ball of your foot. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Copyright 2003 by the American Academy of Family Physicians. Proper . combination of force and joint positioning causes attenuation or tearing of the plantar capsular-ligamentous complex, tear to capsular-ligamentous-seasmoid complex, tear occurs off the proximal phalanx, not the metatarsal, cartilaginous injury or loose body in hallux MTP joint, articulation between MT and proximal phalanx, abductor hallucis attaches to medial sesamoid, adductor hallucis attaches to lateral sesamoid, attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep transverse intermetatarsal ligament, mechanism of injury consistent with hyper-extension and axial loading of hallux MTP, inability to hyperextend the joint without significant symptoms, comparison of the sesamoid-to-joint distances, often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs, negative radiograph with persistent pain, swelling, weak toe push-off, hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture, persistent pain, swelling, weak toe push-off, used to rule out stress fracture of the proximal phalanx, nonoperative modalities indicated in most injuries (Grade I-III), taping not indicated in acute phase due to vascular compromise with swelling, stiff-sole shoe or rocker bottom sole to limit motion, more severe injuries may require walker boot or short leg cast for 2-6 weeks, progressive motion once the injury is stable, headless screw or suture repair of sesamoid fracture, joint synovitis or osteochondral defect often requires debridement or cheilectomy, abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored, immediate post-operative non-weight bearing, treat with cheilectomy versus arthrodesis, depending on severity, Can be a devastating injury to the professional athlete, Posterior Tibial Tendon Insufficiency (PTTI).