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. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. 36(1)p. 60-3. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Management is determined by the location of the fracture and its effect on balance and weight bearing. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. 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. Follow-up/referral. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. A 19-year-old cross country runner complains of 3 months of foot pain with running. In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. A fractured toe may become swollen, tender, and discolored. All material on this website is protected by copyright. Copyright 2003 by the American Academy of Family Physicians. (OBQ12.89)
He undergoes closed reduction and pinning shown in Figure B to correct alignment. Treatment Most broken toes can be treated without surgery. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Taping your broken toe to an adjacent toe can also sometimes help relieve pain. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. Approximately 10% of all fractures occur in the 26 bones of the foot. 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. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of 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.
They typically involve the medial base of the proximal phalanx and usually occur in athletes. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Although tendon injuries may accompany a toe fracture, they are uncommon. Toe fractures are one of the most common fractures diagnosed by primary care physicians. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. toe phalanx fracture orthobulletsdaniel casey ellie casey. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) 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. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. 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. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. In some cases, a Jones fracture may not heal at all, a condition called nonunion. Fractures of multiple phalanges are common (Figure 3). The metatarsals are the long bones between your toes and the middle of your foot. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Foot fractures range widely in severity, prognosis, and treatment. J AmAcad Orthop Surg, 2001. A, Dorsal PIPJ fracture-dislocation. Copyright 2023 Lineage Medical, Inc. All rights reserved. If the bone is out of place, your toe will appear deformed. 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). This procedure is most often done in the doctor's office. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. (OBQ11.63)
A fracture, or break, in any of these bones can be painful and impact how your foot functions. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. If you have an open fracture, however, your doctor will perform surgery more urgently. Because it is the longest of the toe bones, it is the most likely to fracture. 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). Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury.
Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. 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). Pain is worsened with passive toe extension. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. 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 (Kay 2001) Complications: 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, They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. 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. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints.
Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. This webinar will address key principles in the assessment and management of phalangeal fractures. X-rays. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. Am Fam Physician, 2003. 68(12): p. 2413-8. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. Comminution is common, especially with fractures of the distal phalanx. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. 11(2): p. 121-3. Surgical fixation involves Kirchner wires or very small screws. 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.