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Toe fractures result from a direct blow (from an object falling on an unprotected toe) or a “stubbing” injury. The significance of toe fractures depends upon which digit is affected. Most important is the great toe, as it is the main propulsive segment of the forefoot. Many patients do not present to the Emergency Department, as they consider the injury trivial. Those who do present to the Emergency Department often do so because of severe pain and/or a large subungual hematoma.

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Toe fractures are common injuries that rarely require surgical treatment. They may be completely and definitively managed in the Emergency Department. Most toe fractures require only a properly placed splint. An intraarticular fracture with severe displacement of the great toe may require open reduction and internal fixation to prevent deformity and arthritis in the joint. Complications of a toe fracture include damage to cartilage, hypermobility of fracture segments, malposition, and malunion.

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The foot can be anatomically divided into the forefoot, the midfoot, and the hindfoot (Figure 164-1). The forefoot is composed of the metatarsals and their respective phalanges. Sesamoid bones often lie along the plantar surface of the metatarsal heads. The sesamoid bones of the great toe lie in a groove on the plantar surface of the metatarsal head and within the tendon of its respective flexor hallucis brevis muscle belly.

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Each toe has two pairs of digital nerves that course along the superior and inferior aspects of the digit. The digital artery and vein accompany the nerve. The great toe often receives superficial cutaneous nerves along its dorsal surface.

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Obtain radiographs of the affected toe(s). Anteroposterior and oblique views will demonstrate most fractures. Lateral views may be necessary to identify phalangeal fractures of the great toe. Obtain the lateral projection with toes 2 to 5 passively dorsiflexed to avoid overlap. An alternative method to achieve adequate radiographic views of the great toe in the lateral projection is to insert dental x-ray film between the first and second toes and direct the x-ray beam laterally.1

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The indications for simple splinting of toe fractures are to relieve pain and allow for healing. The management of closed fractures depends on the digit involved. Manage nondisplaced phalangeal fractures of the great toe with buddy taping to the adjacent normal toe as a splint. Mildly displaced phalangeal fractures of the great toe can be reduced using local anesthesia, gentle traction, and buddy taping. Manage nondisplaced phalangeal fractures of toes 2 to 5 with buddy taping. Mildly displaced phalangeal fractures of toes 2 to 5 can be reduced using local anesthesia, gentle traction, and buddy taping. Exact anatomic reduction of toes 2 to 5 is not a concern as long as the general alignment of the toe is satisfactory....

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