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Toe Fracture

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Other Names

  • Phalanx fracture of the foot
  • Digit fracture
  • Toe fracture dislocation
  • Stubbed toe
  • Bedroom fracture
  • Nightstand fracture
  • Nightwalker fracture

Background

  • This page is refers to 'Toe Fractures' or fractures of the Phalanges of the foot

History

Epidemiology

  • Prevalence
    • Represents about 9% of fractures treated in the primary care setting (need citation)
    • About 3% of fractures in children[1]
    • Roughly 3.6% of all fracture in adults (need citation)
  • Incidence
    • Estimated to be between 14.0 and 39.6 cases per 10,000 population[2][3]
  • Location
    • Fractures of the lesser digits (76–83%) is much more common than the great toe (17–24%)[2]

Pathophysiology

  • General
    • Virtually all toe fractures, especially 2-5, can be treated non surgically
  • Stubbed toe
    • Occurs with flexion at the distal phalanx in conjunction with a proximally directed shearing force
    • Fractures and dorsally subluxes one or both phalangeal condyles
  • Toe fractures are often failed to be properly diagnosed, treated due to
    • Presence of more serious illness or trauma
    • Lack of appropriate clinical training
    • Failure to appreciate the integrity of the interphalangeal joints, significance of their range of motion

Mechanism

  • Direct trauma
    • Direct injuries from striking objects
    • Assaults
    • Motor vehicle accidents
    • Falls
    • Recreational and sports activity
  • Indirect trauma
    • Secondary hyperextension (turf toe)
    • Hyperflexion (fall from a height) of the interphalangeal or metatarsophalangeal (MTP) joints
  • So-called “bedroom,” “nightstand,” or “nightwalker” fracture,
    • Results from a sudden abduction force applied to the fifth digit against a bedpost while walking in the dark

Associated Conditions

Pathoanatomy

  • Foot Phalanges
    • Proximal, middle and distal phalanges
    • 1st toe: two phalanges
    • 2nd - 5th toe: generally have 3, although 5th toe may only have two

Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • History
    • Some history of trauma
    • Pain, discomfort with shoes, trouble walking
    • Ecchymosis and edema are common and can extend proximally[4]
    • Between 10 - 25% of digital fractures may present without any symptoms, particularly the 5th[5]
  • Physical Exam: Physical Exam Foot
    • Ecchymosis, edema
    • Deformities are rare
    • Evaluate the nailbed
    • Tenderness to the affected toe
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Typically sufficient to make the diagnosis
  • Findings
    • Most are nondisplaced or minimally displaced
    • Comminution is common, especially of distal phalanx
    • Displaced spiral fractures generally display shortening or rotation
    • Displaced transverse fractures may display angulation
    • In children, toe fractures may involve the physis

CT

  • Not routinely indicated
  • May be needed if multiple foot fractures present

MRI

  • Not routinely needed

Classification

  • Not applicable

Management

Basket weave and buddy splint for fracture of lesser digits[6]
  • Goal
    • Reestablish osseous alignment
    • Maintain normal joint range of motion

Nonoperative

  • Indications
    • Stable, non-displaced fractures
  • General management
    • Elevation
    • Ice
    • Analgesia
  • Immobilization
    • Rigid Surgical Shoe for 4 to 6 weeks
    • Athletic tape, regular walking shoe are not recommended
    • Buddy taping or basket weave splinting can be used to reinforce immobilization
    • Interdigital support such as cotton, lamb's wool, moldable silicon or felt can prevent maceration
  • Pediatric considerations
    • Can consider Short Leg Walking Cast with toe plate in active children
    • Kids heal more quickly, typically in 3 to 4 weeks
  • Weight bearing status
    • Non weight bearing status is not usually required
    • Consider restricting weight bearing in patients with occupations that include excessive standing, kneeling or walking
  • Displaced fractures
    • Closed reduction and immobilization should be attempted
    • Consider Digital Block to minimize pain

Operative

  • Indications
    • Open fractures
    • Inability to reduce displaced fractures
    • Displaced intra-articular fractures
    • Unstable, displaced fractures
    • Pediatric fractures involving the physis
    • Nondisplaced intra-articular fractures involving >25% of the joint space
  • Technique
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Functional outcomes
    • Excellent on the AOFAS midfoot score, VAS scoring system in a study by Vliet-Koppert et al[3]

Complications

  • Malunion
  • Nonunion
  • Deformity
  • Decreased range of motion
  • Foot Osteoarthritis
  • Decreased exercise tolerance

See Also


References

  1. Rennie, Louise, et al. "The epidemiology of fractures in children." Injury 38.8 (2007): 913-922.
  2. 2.0 2.1 Fife, Daniel, and Jerome I. Barancik. "Northeastern Ohio trauma study III: incidence of fractures." Annals of emergency medicine 14.3 (1985): 244-248.
  3. 3.0 3.1 Van Vliet-Koppert, Sabine T., et al. "Demographics and functional outcome of toe fractures." The Journal of foot and ankle surgery 50.3 (2011): 307-310.
  4. Elleby, D. H., and D. E. Marcinko. "Digital fractures and dislocations. Diagnosis and treatment." Clinics in podiatry 2.2 (1985): 233-245.
  5. Venegas, L., J. J. Rainieri, and E. C. Rzonca. "Fracture of the fifth digit. An atypical presentation." Journal of the American Podiatric Medical Association 85.3 (1995): 166-168.
  6. Schnaue-Constantouris, Eileen M., et al. "Digital foot trauma: emergency diagnosis and treatment." The Journal of emergency medicine 22.2 (2002): 163-170.
Created by:
John Kiel on 2 November 2021 13:15:43
Authors:
Last edited:
4 October 2022 12:36:13
Categories:
Lower Extremity | Trauma | Foot | Fractures | Acute