From the Guidelines
The management of a tuft open fracture of the great toe should prioritize immediate antibiotic therapy, thorough wound cleansing, and immobilization to prevent infection and promote healing. The initial step in managing such a fracture involves early delivery of antibiotics to lower the risk of deep infection, as suggested by the American Academy of Orthopaedic Surgeons in their clinical practice guideline summary from 2023 1. This approach is crucial for reducing the risk of surgical site infection after major extremity trauma, including open fractures of the great toe.
Key aspects of the management include:
- Thorough wound cleansing with sterile saline or antiseptic solution to remove any debris and assess the nail bed integrity.
- Administration of antibiotics, such as a first-generation cephalosporin, to prevent infection, as the use of antibiotics is suggested to lower the risk of deep infection in open fractures 1.
- Tetanus prophylaxis should be considered based on the patient's immunization status.
- Pain management using acetaminophen or NSAIDs.
- Immobilization of the toe through buddy taping to an adjacent toe and protection with a post-operative shoe or hard-soled shoe.
Follow-up care is essential to monitor the healing process and to identify any potential complications early, such as osteomyelitis or nail deformities. The goal of this management strategy is to minimize morbidity, reduce the risk of mortality from infection, and improve the quality of life for the patient by promoting effective healing and preventing long-term complications.
From the Research
Management of Tuft (Open) Fracture of the Great Toe
The management of a tuft (open) fracture of the great toe involves several key considerations:
- Referral to a specialist 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
- For open fractures, antibiotic agents have been shown to improve outcomes, with ceftriaxone offering a safe and effective alternative for open fracture management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures 3
- The use of prophylactic post-operative antibiotic agents after open reduction internal fixation for closed fractures has been evaluated, with no statistically significant differences found between patients receiving 23 hours of cefazolin or a placebo 4
Treatment Options
Treatment options for great toe fractures include:
- A short leg walking boot or cast with toe plate for two to three weeks, followed by a rigid-sole shoe for an additional three to four weeks 5
- Buddy taping and a rigid-sole shoe for four to six weeks for lesser toe fractures 5
- Referral for stabilization of the reduction for displaced fractures of the first toe 2
Important Considerations
Important considerations in the management of tuft (open) fractures of the great toe include:
- The need for timely and appropriate antibiotic coverage to prevent infection 3, 4
- The importance of evaluating the fracture and determining the best course of treatment based on the location and severity of the fracture 2, 5
- The potential benefits of open reduction and internal fixation in providing a quality-of-life benefit over traditional closed reduction 6