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and S. Hacking, Evaluation and management of toe fractures. Open subtypes (3) Lesser toe fractures. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. (Left) The four parts of each metatarsal. This content is owned by the AAFP. The proximal phalanx is the toe bone that is closest to the metatarsals. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Ulnar gutter splint/cast. He came to the ER at that point to be evaluated. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Stress fractures can occur in toes. This website also contains material copyrighted by third parties. In children, toe fractures may involve the physis (Figure 2). Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. X-rays. Management is influenced by the severity of the injury and the patient's activity level. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. All the bones in the forefoot are designed to work together when you walk. 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. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. MTP joint dislocations. While celebrating the historic victory, he noticed his finger was deformed and painful. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Patients have localized pain, swelling, and inability to bear weight on the. Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. If the bone is out of place, your toe will appear deformed. 50(3): p. 183-6. Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. A combination of anteroposterior and lateral views may be best to rule out displacement. 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. Patients with circulatory compromise require emergency referral. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. 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. All rights reserved. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. Pediatrics, 2006. 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. 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. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Copyright 2003 by the American Academy of Family Physicians. If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe. This is called internal fixation. Magnetic Resonance Imaging (MRI) scans. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). A fractured toe may become swollen, tender, and discolored. 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. An AP radiograph is shown in FIgure A. The pull of these muscles occasionally exacerbates fracture displacement. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). Tang, Pediatric foot fractures: evaluation and treatment. They typically involve the medial base of the proximal phalanx and usually occur in athletes. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Pain is worsened with passive toe extension. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. 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. An X-ray can usually be done in your doctor's office. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. See permissionsforcopyrightquestions and/or permission requests. 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. Fracture Fixation, Internal Bone Plates Fracture Fixation Bone Nails Fracture Fixation, Intramedullary Bone Screws Bone Wires Range of Motion, Articular Hemiarthroplasty Arthroplasty Casts, Surgical Treatment Outcome Arthroplasty, Replacement Internal Fixators Retrospective Studies Bone Transplantation Reoperation Injury . Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks. Proximal hallux. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). (Kay 2001) Complications: Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. 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, Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. 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! Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. If you need surgery it is best that this be performed within 2 weeks of your fracture. Foot Ankle Int, 2015. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. 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. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Follow-up/referral. 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. Clin OrthopRelat Res, 2005(432): p. 107-15. Non-narcotic analgesics usually provide adequate pain relief. 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. Patients with these fractures should be referred to an orthopedist.2,3,6, The fifth metatarsal has the least cortical thickness of all the metatarsals.13 There are multiple strong ligamentous and capsular attachments surrounding the proximal fifth metatarsal; these allow stresses to be directed through this portion of the bone.13 Classically, fractures of the proximal fifth metatarsal can be classified based on anatomic location into one or more of three zones (Figure 7).3. Petnehazy, T., et al., Fractures of the hallux in children. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. 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 ). Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Diagnosis can be made clinically and are confirmed with orthogonal radiographs. The patient notes worsening pain at the toe-off phase of gait. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. 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. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. 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. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. 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. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. 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 of multiple phalanges are common (Figure 3). Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). (OBQ11.63) They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. Epidemiology Incidence The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. Ulnar side of hand. Copyright 2023 American Academy of Family Physicians. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. If you experience any pain, however, you should stop your activity and notify your doctor. Patient examination; . If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. J Pediatr Orthop, 2001. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. If the wound communicates with the fracture site, the patient should be referred. 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. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Fractures can also develop after repetitive activity, rather than a single injury. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. 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. Diagnosis is made with plain radiographs of the foot. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. 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. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. 2017 Oct 01;:1558944717735947. 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.