Management of Salter-Harris Type II Fracture of the Base of the Distal Phalanx of the Great Toe
For a Salter-Harris type II fracture at the base of the distal phalanx of the great toe in a child, obtain radiographs (AP and lateral views) and treat with buddy taping to the adjacent toe plus a rigid-sole shoe for 3-4 weeks if the fracture is nondisplaced and stable.
Initial Evaluation
Start with anteroposterior and oblique radiographs of the foot to document the fracture and assess for displacement 1. Carefully examine for:
- Clinical signs of nail bed injury: subungual hematoma, proximal nail plate subluxation, bleeding from under the nail plate, or eponychial fold laceration
- Fracture displacement or angulation
- Rotational deformity (assess the toe in flexion)
Critical Decision Point: Is This a Seymour Fracture?
If ANY clinical evidence of nail bed violation exists (bleeding at nail fold, nail plate displacement, subungual hematoma), this is a Seymour fracture—an OPEN fracture requiring urgent surgical management 2, 3. The presence of these clinical findings mandates surgical exploration even if radiographs appear benign, as 82% will have nail bed lacerations and 47% will have soft tissue interposition 4.
For Seymour Fractures (Open Injuries):
- Immediate antibiotics (within hours, not days)
- Urgent irrigation and debridement within 24 hours
- Remove interposed germinal matrix or nail bed tissue from the fracture site
- Anatomic reduction with percutaneous pinning if unstable
- Delayed treatment beyond 24 hours carries a 45% infection rate versus 0% with acute appropriate treatment 2
For Closed Salter-Harris Type II Fractures
Nondisplaced or Minimally Displaced Fractures:
- Buddy tape to the second toe
- Rigid-sole shoe to limit joint movement 5
- Immobilization for 3-4 weeks
- These selected nondisplaced Salter-Harris I and II fractures can be managed by primary care physicians 5
Displaced Fractures:
Refer to orthopedics if:
- Displacement involves >25% of the joint surface
- Fracture is unstable after attempted reduction
- Significant angulation persists (>10 degrees)
- Open fracture or circulatory compromise present 5
Displaced fractures of the first toe often require referral for stabilization, as the great toe bears significant weight and functional demands 5.
Common Pitfalls
The most dangerous error is missing a Seymour fracture. Do not be falsely reassured by minimal radiographic findings—clinical evidence of nail bed injury trumps imaging 3. These injuries appear innocuous but carry severe consequences (osteomyelitis, physeal arrest, nail deformity) when undertreated 2.
Do not apply the Ottawa foot rules to toe fractures—they don't directly address distal forefoot trauma. When a toe fracture is suspected clinically, obtain radiographs regardless 1.