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This joint sits between the proximal phalanx and a bone in the hand . Radiographs often are required to distinguish these injuries from toe fractures. The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Diagnosis is made with plain radiographs of the foot. 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. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. 11(2): p. 121-3. For several days, it may be painful to bear weight on your injured toe. Am Fam Physician, 2003. 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. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. Physical examination reveals marked tenderness to palpation. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. This website also contains material copyrighted by third parties. Toe and forefoot fractures often result from trauma or direct injury to the bone. Your doctor will tell you when it is safe to resume activities and return to sports. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. All the bones in the forefoot are designed to work together when you walk. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Distal metaphyseal. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. Approximately 10% of all fractures occur in the 26 bones of the foot. Foot fractures range widely in severity, prognosis, and treatment. Your doctor will then examine your foot and may compare it to the foot on the opposite side. Pain is worsened with passive toe extension. Each metatarsal has the following four parts: Fractures can occur in any part of the metatarsal, but most often occur in the neck or shaft of the bone. J Pediatr Orthop, 2001. 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. At the conclusion of treatment, radiographs should be repeated to document healing. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. 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. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. 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. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Hallux fractures. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. 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. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. 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). Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. A 55 year-old woman comes to you with 2 months of right foot pain. Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. 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. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. toe phalanx fracture orthobullets Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. 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 . In some cases, a Jones fracture may not heal at all, a condition called nonunion. 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. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? He came to the ER at that point to be evaluated. 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. 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 Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. (OBQ11.63) J AmAcad Orthop Surg, 2001. Patient examination; . Surgery is not often required. 2017 Oct 01;:1558944717735947. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. While many Phalangeal fractures can be treated non-operatively, some do require surgery. 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. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Ulnar gutter splint/cast. The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. (OBQ12.89) 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 toe phalanx fracture orthobulletsforeign birth registration ireland forum. Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. Fractures of the toes and forefoot are quite common. 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. 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. Unlike an X-ray, there is no radiation with an MRI. There are 3 phalanges in each toe except for the first toe, which usually has only 2. The pull of these muscles occasionally exacerbates fracture displacement. Pediatrics, 2006. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Radiographs are shown in Figure A. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Referral is indicated if buddy taping cannot maintain adequate reduction. Healing rates also vary considerably depending on the age of the patient and comorbidities. 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. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. All rights reserved. 24(7): p. 466-7. All material on this website is protected by copyright. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. An X-ray can usually be done in your doctor's office. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. If you need surgery it is best that this be performed within 2 weeks of your fracture. 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. Vollman, D. and G.A. At the first follow-up visit, radiography should be performed to assure fracture stability. 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. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. (Right) The bones in the angled toe have been manipulated (reduced) back into place. 50(3): p. 183-6. 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. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Author disclosure: No relevant financial affiliations. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. and C.W. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. A, Dorsal PIPJ fracture-dislocation. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Bicondylar proximal phalanx fractures usually are treated with plate fixation. Copyright 2023 American Academy of Family Physicians. 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. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. 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). Although tendon injuries may accompany a toe fracture, they are uncommon. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Patients with circulatory compromise require emergency referral. 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. Stress fractures can occur in toes. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. ClinPediatr (Phila), 2011. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. 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. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Open subtypes (3) Lesser toe fractures. and S. Hacking, Evaluation and management of toe fractures. 2 ). Continue to learn and join meaningful clinical discussions . The "V" sign (arrow) indicates dorsal instability. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Patients with intra-articular fractures are more likely to develop long-term complications. Thank you. 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. The fractures reviewed in this article are summarized in Table 1. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Your foot may become swollen and discolored after a fracture. A fractured toe may become swollen, tender, and discolored. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Management is determined by the location of the fracture and its effect on balance and weight bearing. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. 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. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. All Rights Reserved. All Rights Reserved. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) 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. This webinar will address key principles in the assessment and management of phalangeal fractures. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. If it does not, rotational deformity should be suspected. If you experience any pain, however, you should stop your activity and notify your doctor. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. 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. Non-narcotic analgesics usually provide adequate pain relief. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. While on call at the local rural community hospital, you're called by an emergency medicine colleague. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. (SBQ17SE.89) Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. 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. There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Shaft. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. Injuries to this bone may act differently than fractures of the other four metatarsals. 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. Follow-up/referral. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. This is called internal fixation. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. Copyright 2016 by the American Academy of Family Physicians. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. 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. 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. Which of the following is true regarding open reduction and screw fixation of this injury? Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) Because it is the longest of the toe bones, it is the most likely to fracture. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. 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. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Treatment Most broken toes can be treated without surgery. Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. 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. For athletes and other highly active persons, evidence shows earlier return to activity with surgical management; therefore, surgery is recommended.13,21,22 In contrast, patients treated with nonsurgical techniques should be counseled about longer healing time and the possibility that surgery may be needed despite conservative management.2,13,2022, Patients with fifth metatarsal tuberosity avulsion fractures should be referred to an orthopedist if there is more than 3 mm of displacement, if step-off is greater than 1 to 2 mm on the cuboid articular surface, or if a fragment includes more than 60% of the metatarsal-cuboid joint surface. A combination of anteroposterior and lateral views may be best to rule out displacement. Epidemiology Incidence 36(1)p. 60-3. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. X-rays provide images of dense structures, such as bone. Copyright 2003 by the American Academy of Family Physicians. Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Clinical Features Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. As your pain subsides, however, you can begin to bear weight as you are comfortable. 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. They most often involve the metatarsals and toes. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. This procedure is most often done in the doctor's office.