Management of Toe Fractures
Most toe fractures can be managed conservatively with buddy taping and a rigid-sole shoe for 4-6 weeks, with special attention given to great toe fractures due to their role in weight-bearing. 1, 2
Diagnosis
Clinical Presentation:
- Point tenderness at the fracture site
- Pain with gentle axial loading of the digit
- Swelling of the affected area
- Difficulty with ambulation
Imaging:
- Anteroposterior and oblique radiographs are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges 3
- Weight-bearing views should be obtained when possible 4
- CT may be useful for complex fractures or when radiographs are inconclusive 1
- MRI is the most sensitive for detecting occult fractures with persistent pain after negative radiographs 1
Treatment Algorithm
1. Lesser Toe Fractures (2nd-5th toes)
Stable, nondisplaced fractures:
- Buddy taping to adjacent toe
- Rigid-sole shoe for 4-6 weeks
- Weight-bearing as tolerated
Displaced fractures:
- Closed reduction
- Buddy taping after reduction
- Rigid-sole shoe for 4-6 weeks
2. Great Toe (Hallux) Fractures
Nondisplaced fractures:
- Short leg walking boot or cast with toe plate for 2-3 weeks
- Transition to rigid-sole shoe for additional 3-4 weeks 2
Displaced fractures:
- Require more aggressive management due to the toe's role in weight-bearing
- Consider orthopedic referral for stabilization of the reduction 3
3. Indications for Orthopedic Referral 3
- Circulatory compromise
- Open fractures
- Significant soft tissue injury
- Fracture-dislocations
- Displaced intra-articular fractures
- Great toe fractures that are unstable
- Great toe fractures involving >25% of the joint surface
- Pediatric physeal fractures (especially Salter-Harris types III and IV)
Pain Management
- NSAIDs (ibuprofen 400-600mg three times daily) for pain and inflammation 1
- Acetaminophen if NSAIDs are contraindicated 1
Follow-up and Prognosis
- Most toe fractures heal well with conservative management
- Average time to bony union: 8.3 weeks 1
- Time to pain-free walking: 4.6-8.4 weeks 1
- Return to normal footwear: 6-7.3 weeks 1
Important Considerations
- Routine follow-up in fracture clinic may not be necessary for uncomplicated toe fractures 5
- A study showed that only 2 out of 65 patients with toe fractures required surgery, and no patients developed symptomatic malunion over 2 years 5
- Complications are rare but may include arthritis, infection, malunion or nonunion 4
Special Cases
Seymour Fractures (open physeal fractures of the distal phalanx with nail bed injury):
- Often missed by initial providers
- Require surgical management to prevent infection, pain, nail deformity, and physeal arrest 6
Pediatric Fractures:
- Children with nondisplaced Salter-Harris types I and II fractures may be treated conservatively
- Most other pediatric physeal fractures should be referred to orthopedics 3
The evidence strongly supports that most toe fractures can be managed effectively with simple conservative measures, and routine fracture clinic follow-up may be unnecessary for uncomplicated cases, which could reduce healthcare burden 5.