Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. - 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; If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). 24(7): p. 466-7. Diagnosis is made clinically with the inability to hyperextend the hallux MTP joint without significant pain and the inability to push off with the big toe. Lesser toe fractures are about twice as common as great toe fractures.23,24 The great toe has an increased role in weight bearing and balance; thus, injury to the great toe is associated with higher morbidity.6,24, The primary goals of treating toe fractures include reestablishing and maintaining alignment, regaining range of motion, and preventing complications. Healing of a broken toe may take 6 to 8 weeks. Your foot may become swollen and discolored after a fracture. fractures of the head of the proximal phalanx. Healing time is typically four to six weeks. 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. If the wound communicates with the fracture site, the patient should be referred. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. While celebrating the historic victory, he noticed his finger was deformed and painful. While many Phalangeal fractures can be treated non-operatively, some do require surgery. 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. In most cases, a fracture will heal with rest and a change in activities. What is the most likely diagnosis? An AP radiograph is shown in FIgure A. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. imbalance after flexor tendon repair seems to be thus, extensor tendon injuries occur frequently an in depth understanding of the intricate anatomy of the extensor mechanism is necessary to guide management careful counseling is helpful in Plate fixation . 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. Surgery is not often required. 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. Your doctor will tell you when it is safe to resume activities and return to sports. Proximal phalanx fractures often present with apex volar angulation. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. See permissionsforcopyrightquestions and/or permission requests. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. Copyright 2023 Lineage Medical, Inc. All rights reserved. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. Bicondylar proximal phalanx fractures usually are treated with plate fixation. X-rays provide images of dense structures, such as bone. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. While on call at the local rural community hospital, you're called by an emergency medicine colleague. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. (OBQ11.63) 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. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Copyright 2016 by the American Academy of Family Physicians. Epidemiology Incidence Tang, Pediatric foot fractures: evaluation and treatment. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. If you experience any pain, however, you should stop your activity and notify your doctor. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. Patients with circulatory compromise require emergency referral. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. A fractured toe may become swollen, tender, and discolored. The fifth metatarsal is the long bone on the outside of your foot. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. X-rays. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). 21(1): p. 31-4. 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. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. This information is provided as an educational service and is not intended to serve as medical advice. At the first follow-up visit, radiography should be performed to assure fracture stability. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for two weeks, with progressive mobility as tolerated after initial immobilization. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. 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. 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. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. J AmAcad Orthop Surg, 2001. (SBQ17SE.3) 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. This website also contains material copyrighted by third parties. Background: The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons. Am Fam Physician, 2003. 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. 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. METHODS: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Toe and forefoot fractures often result from trauma or direct injury to the bone. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. At the conclusion of treatment, radiographs should be repeated to document healing. myAO. In some cases, a Jones fracture may not heal at all, a condition called nonunion. protected weightbearing with crutches, with slow return to running. (Left) The four parts of each metatarsal. Copyright 2023 American Academy of Family Physicians. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. Epub 2017 Oct 1. The video will appear on the video dashboard once complete. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. 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. The most common symptoms of a fracture are pain and swelling. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. 36(1)p. 60-3. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. All the bones in the forefoot are designed to work together when you walk. The fractures reviewed in this article are summarized in Table 1. 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). When this happens, surgery is often required. 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. The most common injury in children is a fracture of the neck of the talus. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Thank you. and C.W. Epidemiology Incidence Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Treatment Most broken toes can be treated without surgery. Ulnar side of hand. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Copyright 2003 by the American Academy of Family Physicians. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Lightly wrap your foot in a soft compressive dressing. Proper . See permissionsforcopyrightquestions and/or permission requests. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Tuberosity avulsion fractures are generally found in zone 1 and do not extend into the joint between the fourth and fifth metatarsal bases (Figures 7 and 9). 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. Healing rates also vary considerably depending on the age of the patient and comorbidities. 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 . Patient examination; . Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Continue to learn and join meaningful clinical discussions . Pearls/pitfalls. There should be at least three images of the affected toe, including anteroposterior, lateral, and oblique views, with visualization of the adjacent toes and of the joints above and below the suspected fracture location. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Shaft. (Kay 2001) Complications: These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. Diagnosis is made with plain radiographs of the foot. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Copyright 2023 American Academy of Family Physicians. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. 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. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). 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. Hallux fractures. Foot fractures are among the most common foot injuries evaluated by primary care physicians. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. This is called internal fixation. 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. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Patients with intra-articular fractures are more likely to develop long-term complications. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. This joint sits between the proximal phalanx and a bone in the hand . 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. 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. Toe fractures are one of the most common fractures diagnosed by primary care physicians. A combination of anteroposterior and lateral views may be best to rule out displacement. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Comminution is common, especially with fractures of the distal phalanx. Proximal hallux. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Copyright 2023 Lineage Medical, Inc. All rights reserved. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks.