Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. J AmAcad Orthop Surg, 2001. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. 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. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Healing time is typically four to six weeks. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. The video will appear on the video dashboard once complete. Which of the following is true regarding open reduction and screw fixation of this injury? Returning to activities too soon can put you at risk for re-injury. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Copyright 2016 by the American Academy of Family Physicians. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. It ossifies from one center that appears during the sixth month of intrauterine life. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. Your doctor will tell you when it is safe to resume activities and return to sports. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. toe phalanx fracture orthobulletsdaniel casey ellie casey. A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. 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. Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. X-rays. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. 118(2): p. e273-8. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. 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. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. If it does not, rotational deformity should be suspected. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Lgters TT,
She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Most fractures can be seen on a routine X-ray. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Radiographs are shown in Figure A. Your doctor will then examine your foot and may compare it to the foot on the opposite side. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. If the bone is out of place, your toe will appear deformed. 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. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. Pediatr Emerg Care, 2008. protected weightbearing with crutches, with slow return to running.
Toe and forefoot fractures often result from trauma or direct injury to the bone. Surgery is not often required. Most broken toes can be treated without surgery. The proximal phalanx is the phalanx (toe bone) closest to the leg. Surgery may be delayed for several days to allow the swelling in your foot to go down. Your foot may become swollen and discolored after a fracture. (Left) The four parts of each metatarsal. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. Patients have localized pain, swelling, and inability to bear weight on the. Management is determined by the location of the fracture and its effect on balance and weight bearing. If you experience any pain, however, you should stop your activity and notify your doctor. While many Phalangeal fractures can be treated non-operatively, some do require surgery. The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. The metatarsals are the long bones between your toes and the middle of your foot. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. 21(1): p. 31-4. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. This joint sits between the proximal phalanx and a bone in the hand . Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Diagnosis is made with plain radiographs of the foot. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. This procedure is most often done in the doctor's office. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement.
Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Clin J Sport Med, 2001. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury.