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. Bicondylar proximal phalanx fractures usually are treated with plate fixation. There are 3 phalanges in each toe except for the first toe, which usually has only 2. 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. 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. Radiographs are shown in Figure A. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. The fractures reviewed in this article are summarized in Table 1. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. 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. This topic will review the evaluation and management of toe fractures in adults. Hand (N Y). 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. 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. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. It ossifies from one center that appears during the sixth month of intrauterine life. The nail should be inspected for subungual hematomas and other nail injuries. stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate Search dates: February and June 2015. Hatch, R.L. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. The talus has a head, constricted neck, and body. 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). Adjacent metatarsals should be examined, and neurovascular status should be assessed. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. Healing rates also vary considerably depending on the age of the patient and comorbidities. MTP joint dislocations. fractures of the head of the proximal phalanx. 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. Ulnar gutter splint/cast. Bony deformity is often subtle or absent. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) The "V" sign (arrow) indicates dorsal instability. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. Pearls/pitfalls. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. 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. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Surgical fixation involves Kirchner wires or very small screws. 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. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. In children, toe fractures may involve the physis (Figure 2). Most commonly, the fifth metatarsal fractures through the base of the bone. 2 ). Rotator Cuff and Shoulder Conditioning Program. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Proximal phalanx fractures often present with apex volar angulation. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. 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. Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Most broken toes can be treated without surgery. Radiographs often are required to distinguish these injuries from toe fractures. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. 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. 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. 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. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the 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. Pediatrics, 2006. This webinar will address key principles in the assessment and management of phalangeal fractures. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. 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). 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. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. 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. 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. 9(5): p. 308-19. The most common injury in children is a fracture of the neck of the talus. 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. If the bone is out of place, your toe will appear deformed. Your foot may become swollen and discolored after a fracture. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Healing time is typically four to six weeks. 24(7): p. 466-7. Because it is the longest of the toe bones, it is the most likely to fracture. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. He came to the ER at that point to be evaluated. Vollman, D. and G.A. Epidemiology Incidence toe phalanx fracture orthobulletsdaniel casey ellie casey. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. 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. Taping may be necessary for up to six weeks if healing is slow or pain persists. 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 34-year-old male sustains the closed finger injury shown in Figure A one week ago. Management is influenced by the severity of the injury and the patient's activity level. A proximal phalanx is a bone just above and below the ball of your foot. protected weightbearing with crutches, with slow return to running. Distal metaphyseal. This webinar will address key principles in the assessment and management of phalangeal fractures. 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. 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. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. Referral is indicated if buddy taping cannot maintain adequate reduction. They typically involve the medial base of the proximal phalanx and usually occur in athletes. 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. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. At the conclusion of treatment, radiographs should be repeated to document healing. Petnehazy, T., et al., Fractures of the hallux in children. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. If you have an open fracture, however, your doctor will perform surgery more urgently. The patient notes worsening pain at the toe-off phase of gait. Follow-up/referral. 21(1): p. 31-4. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. Fractures can also develop after repetitive activity, rather than a single injury. Copyright 2023 American Academy of Family Physicians. (SBQ17SE.3) 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. The localized tenderness of a contusion may mimic the point tenderness of a fracture. Copyright 2023 Lineage Medical, Inc. All rights reserved. Clin J Sport Med, 2001. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Most fractures can be seen on a routine X-ray. Toe fractures are one of the most common fractures diagnosed by primary care physicians. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. (OBQ09.156) 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. 68(12): p. 2413-8. Copyright 2023 American Academy of Family Physicians. There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. Stress fractures can occur in toes. 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. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? See permissionsforcopyrightquestions and/or permission requests. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. What is the most likely diagnosis? If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. Thus, this article provides general healing ranges for each fracture. This content is owned by the AAFP. As your pain subsides, however, you can begin to bear weight as you are comfortable. Differential Diagnosis The same mechanisms that produce toe fractures. Your doctor will tell you when it is safe to resume activities and return to sports. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) J Pediatr Orthop, 2001. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. 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. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Mounts, J., et al., Most frequently missed fractures in the emergency department. Lightly wrap your foot in a soft compressive dressing. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Your video is converting and might take a while Feel free to come back later to check on it. Clin OrthopRelat Res, 2005(432): p. 107-15. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. 118(2): p. e273-8. 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. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. This information is provided as an educational service and is not intended to serve as medical advice. 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. and S. Hacking, Evaluation and management of toe fractures. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). Copyright 2023 Lineage Medical, Inc. All rights reserved. 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. (OBQ05.209) 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 Epub 2012 Mar 30. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. Proximal metaphyseal. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? 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! abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. 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. For several days, it may be painful to bear weight on your injured toe. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. Objective Evidence Three muscles, viz. During this time, it may be helpful to wear a wider than normal shoe. Foot phalanges. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. The most common symptoms of a fracture are pain and swelling. 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.