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.
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.
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.
The bony anatomy of the foot.
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.
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
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....