Toe phalangeal fractures

The most common fractures of the foot. Lesser toe fractures almost always heal with simple buddy taping. The hallux is different: it takes a large share of push-off, so intra-articular fractures of the metatarsophalangeal or interphalangeal joints and displaced shaft fractures of the big toe deserve accurate reduction.

Mechanism

Stubbing against furniture (the "bedroom fracture" of the fifth toe, usually forced into abduction); a heavy object dropped on the foot (crush of the distal phalanx, often open with a nail bed injury); hyperextension or hyperflexion of the hallux in sport.

Clinical findings

• Swelling, bruising and tenderness of the toe; deformity or malrotation (compare the nail plates with the other toes).
• Subungual haematoma or a nail bed laceration over a distal phalanx fracture makes it an open fracture.
• Check capillary refill after crush injuries.

Imaging

• AP, oblique and lateral of the injured toe(s).
• Hallux: look for an articular step at the MTP and IP joints and for sesamoid fractures.

• AP, oblique and lateral of the toes (the lateral isolates the injured toe with the others flexed out of the way).
• Look for intra-articular extension and a step at the hallux MTP and IP joints; sesamoid fractures can mimic or accompany them (a bipartite sesamoid is smooth and often bilateral).

Classification

88.1

Hallux (proximal and distal phalanx).

88.2–88.5

Second to fifth toes, then phalanx (proximal, middle, distal) and location (base, shaft, head).

Extra- vs intra-articular

The key practical split for the hallux: intra-articular fragments with more than about 2 mm of step or a quarter of the joint surface are fixed.

Types shown in 3D

Hallux proximal phalanx, extra-articular

Shaft fracture of the proximal phalanx of the big toe: the distal fragment angulates (here into valgus and dorsiflexion). Reduce and tape; unstable fractures need K-wires.

Hallux, intra-articular (condylar)

A condyle of the proximal phalanx head shears off into the interphalangeal joint (unicondylar). A step of more than about 2 mm or a large fragment: ORIF with a mini-screw.

Hallux distal phalanx (tuft)

Crush of the tip of the big toe by a dropped object: comminuted tuft fracture, usually undisplaced, often with a subungual haematoma or a nail bed laceration (open fracture).

Lesser toe (fifth) proximal phalanx

The "bedroom fracture": the fifth toe catches a doorframe or furniture and the oblique fracture angulates into abduction. Reduce under a digital block if deformed, then buddy-tape to the fourth toe for 3–4 weeks.

Treatment

Lesser toes

Buddy taping to the neighbour and a stiff-soled shoe for 3–4 weeks. Reduce a clinically angulated or rotated toe under a digital block first (traction over a pencil). Fixation is rarely needed: an unstable, irreducible or grossly displaced intra-articular fracture.

Hallux, extra-articular

Undisplaced or stable after reduction: buddy taping or a walking cast/boot with a toe extension. Unstable, angulated or rotated: K-wires or screws.

Hallux, intra-articular

Displaced condylar or basal fragments (> 2 mm, or a large joint fragment): ORIF with mini-screws or K-wires to prevent hallux rigidus and IP arthritis.

Distal phalanx crush

Drain a painful subungual haematoma; with a nail bed laceration, wash out, repair the bed and give antibiotics (open fracture).

Aftercare

Walking as pain allows in a stiff shoe; most return to normal footwear by 4–6 weeks.

Complications

• Malunion with a painful prominence or a rotated toe rubbing in the shoe
• Hallux MTP or IP stiffness and arthritis after intra-articular fractures
• Nail deformity and infection after open distal phalanx fractures