Toe fractures are the most common fracture of the foot. They result most commonly from a direct blow (e.g., from an object falling on an unprotected toe) or a “stubbing” injury.1,2 The incidence of toe fractures has been estimated at 140 cases per 100,000 people per year, with the first and fifth toes being the most commonly affected.1,3 The significance of toe fractures depends greatly upon which digit is affected. Most significant is a fracture of the great toe due to being the main propulsive segment of the forefoot.4 Many patients do not present to the Emergency Department as they consider the injury trivial. Those who do present often do so because of severe pain and/or a large subungual hematoma.
Toe fractures are common injuries that rarely require surgical treatment. The primary goals of treating toe fractures are reestablishing and maintaining alignment, regaining range of motion, preventing complications, and managing pain. They may be completely and definitively managed in the Emergency Department. Most toe fractures require only a properly placed splint. Between 91% and 97% of toe fractures are nondisplaced or minimally displaced. These fractures often require a closed reduction.1,5 An intraarticular fracture with severe displacement of the great toe may require an open reduction and internal fixation to prevent deformity and arthritis in the joint. Complications of toe fractures include damage to the articular cartilage, hypermobility of fracture segments, malposition, and malunion.
ANATOMY AND PATHOPHYSIOLOGY
The foot can be anatomically divided into the forefoot, the midfoot, and the hindfoot (Figure 220-1). 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. 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.
The bony anatomy of the foot.
Anteroposterior and oblique radiographic 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 through 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.6
The indications for simple splinting of toe fractures are to relieve pain and allow for healing. The management of ...