From the Guidelines
Surgery is usually not the first line of treatment for toe phalanx fractures, and is typically reserved for cases where fracture fragments are large, articular, or significantly displaced. When considering surgical intervention for toe phalanx fractures, it's essential to evaluate the fracture's characteristics, such as displacement, angulation, and involvement of the joint surface. According to the American College of Foot and Ankle Surgeons 1, the diagnosis of toe phalanx fractures is based on a history of trauma, focal pain on palpation, and radiographic confirmation.
The decision to operate on a toe phalanx fracture depends on various factors, including:
- The size and displacement of the fracture fragments
- The involvement of the joint surface
- The presence of soft tissue damage or open fracture
- The stability of the fracture and the ability to achieve adequate reduction with closed methods
- The presence of rotational deformity that would impair normal foot function
In general, surgical intervention may be considered for fractures that are significantly displaced, angulated, or involve a large portion of the joint surface. However, for small, nonarticular, or minimally displaced fractures, simple immobilization may be sufficient 1.
It's crucial to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions, and to consider the potential risks and benefits of surgical intervention. In the context of real-life clinical medicine, a conservative approach may be preferred when possible, reserving surgery for cases where the benefits outweigh the risks.
From the Research
Surgical Indication for Toe Phalanx Fracture
- The decision to operate on a toe phalanx fracture depends on several factors, including the type and severity of the fracture, as well as the presence of any complications 2.
- Referral for surgical evaluation 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 2.
- Surgical management is also indicated for displaced, intra-articular (physeal) fractures, which can offer satisfactory return to sport rates and times 3.
- Open reduction and internal fixation using screw/plate osteosynthesis is recommended for extra-articular fractures with clinically evident malrotation of the finger, comminution fracture and/or loss of length, which cannot be treated non-operatively 4.
- Intra-articular fracture with step off greater than 1 mm, which cannot be treated percutaneously but openly using plate/screw osteosythesis, is also an indication for surgical management 4.
Specific Fracture Types
- For acute fractures, surgical management is indicated for displaced intra-articular fractures, while conservative management is often sufficient for non-displaced fractures 3.
- For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity 3.
- Proximal phalanx fractures with rotational malalignment can be corrected with anatomic reduction by open reduction and internal fixation, resulting in good clinical outcomes 5.
Treatment Options
- Open reduction and internal fixation using screw/plate osteosynthesis provides good results in combination with immediate mobilization 4.
- Percutaneous fixation with K-wires is often sufficient for proximal phalanx fractures and is associated with better aesthetic outcomes than open reduction and internal fixation 6.
- Buddy taping and a rigid-sole shoe can be used to treat stable, non-displaced toe fractures, while displaced fractures may require reduction and buddy taping 2.