The fifth metatarsal is the long bone on the outside of your foot. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. A fractured toe may become swollen, tender, and discolored. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). Content is updated monthly with systematic literature reviews and conferences. Taping may be necessary for up to six weeks if healing is slow or pain persists. PMID: 22465516. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. At the first follow-up visit, radiography should be performed to assure fracture stability. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Clin J Sport Med, 2001. The video will appear on the video dashboard once complete. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. A 55 year-old woman comes to you with 2 months of right foot pain. toe phalanx fracture orthobulletsdaniel casey ellie casey. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Proximal metaphyseal. X-rays. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. The pull of these muscles occasionally exacerbates fracture displacement. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Epub 2017 Oct 1. The younger the child, the more . Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. Three muscles, viz. Foot phalanges. Treatment is generally straightforward, with excellent outcomes. During this time, it may be helpful to wear a wider than normal shoe. Copyright 2016 by the American Academy of Family Physicians. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. Hallux fractures. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. This joint sits between the proximal phalanx and a bone in the hand . Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Unlike an X-ray, there is no radiation with an MRI. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. and S. Hacking, Evaluation and management of toe fractures. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. On exam, he is neurovascularly intact. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Joint hyperextension and stress fractures are less common. The nail should be inspected for subungual hematomas and other nail injuries. Returning to activities too soon can put you at risk for re-injury. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. High-impact activities like running can lead to stress fractures in the metatarsals. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Distal metaphyseal. Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf A fracture, or break, in any of these bones can be painful and impact how your foot functions. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. 2017 Oct 01;:1558944717735947. Approximately 10% of all fractures occur in the 26 bones of the foot. Non-narcotic analgesics usually provide adequate pain relief. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Objective Evidence An X-ray can usually be done in your doctor's office. Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. An AP radiograph is shown in FIgure A. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Copyright 2023 Lineage Medical, Inc. All rights reserved. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. Which of the following is true regarding open reduction and screw fixation of this injury? Most broken toes can be treated without surgery. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Referral is indicated if buddy taping cannot maintain adequate reduction. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. Copyright 2023 American Academy of Family Physicians. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. 118(2): p. e273-8. Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. (Left) The four parts of each metatarsal. The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). There should be at least three images of the affected toe, including anteroposterior, lateral, and oblique views, with visualization of the adjacent toes and of the joints above and below the suspected fracture location. While on call at the local rural community hospital, you're called by an emergency medicine colleague. If the wound communicates with the fracture site, the patient should be referred. All rights reserved. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. (OBQ05.209) Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. . Magnetic Resonance Imaging (MRI) scans. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. Diagnosis is made with plain radiographs of the foot. Some metatarsal fractures are stress fractures. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. Most commonly, the fifth metatarsal fractures through the base of the bone. Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Injuries to this bone may act differently than fractures of the other four metatarsals. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Ulnar side of hand. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. The patient notes worsening pain at the toe-off phase of gait. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. See permissionsforcopyrightquestions and/or permission requests. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. Because it is the longest of the toe bones, it is the most likely to fracture. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures Clin OrthopRelat Res, 2005(432): p. 107-15. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. The proximal phalanx is the phalanx (toe bone) closest to the leg. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. Background: The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons. Plate fixation . Proximal phalanx (finger) fracture Contents 1 Background The flexor digitorum superficialis (FDS) inserts at the middle of the phalanx and can cause rotational deformity [1] Extensor tendons and interosseous muscles commonly causes volar angulation [1] Clinical Features Finger pain Differential Diagnosis Hand and Finger Fractures All Rights Reserved. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. Pain is worsened with passive toe extension. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. For several days, it may be painful to bear weight on your injured toe. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Because it is the longest of the toe bones, it is the most likely to fracture. (SBQ17SE.3) Thank you. If it does not, rotational deformity should be suspected. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. A combination of anteroposterior and lateral views may be best to rule out displacement. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? Am Fam Physician, 2003. 11(2): p. 121-3. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). He came to the ER at that point to be evaluated. fractures of the head of the proximal phalanx. Continue to learn and join meaningful clinical discussions . Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Note that the volar plate (VP) attachment is involved in the . Toe fractures are one of the most common fractures diagnosed by primary care physicians. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. The most common symptoms of a fracture are pain and swelling. Epidemiology Incidence Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. Phalangeal fractures are the most common foot fracture in children. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position.
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