What is the initial management for an acute minimally displaced intra-articular fracture of the dorsal aspect of the base of the distal phalanx of the left second toe?

Management of Acute Minimally Displaced Intra-articular Fracture of Dorsal Aspect of Base of Distal Phalanx of Left Second Toe

The initial management for an acute minimally displaced intra-articular fracture of the dorsal aspect of the base of the distal phalanx of the left second toe should be conservative treatment with immobilization using buddy taping to the adjacent toe, followed by early range of motion exercises. This approach prioritizes functional outcomes while minimizing complications associated with more invasive interventions.

Initial Assessment and Imaging

• Standard radiographic examination should include multiple views to properly visualize the fracture 1
• For phalangeal injuries, some centers include a PA examination of the entire foot, while others limit examination to the injured toe
• An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 1
• If initial radiographs are equivocal but clinical suspicion remains high, consider:
  • Repeat radiographs in 7-10 days 2
  • CT without IV contrast for better visualization of fracture morphology in complex cases 1

Treatment Protocol

Conservative Management

• For minimally displaced intra-articular fractures of the distal phalanx:
  1. Buddy taping to adjacent toe to provide stability while allowing some motion
  2. Protective footwear with a stiff sole to prevent excessive toe flexion
  3. Weight-bearing as tolerated with appropriate footwear
  4. Ice application during the first 3-5 days for symptomatic relief 2
  5. Elevation to reduce swelling

Pain Management

• NSAIDs for pain and inflammation control 2
• Oral analgesics for residual pain as needed 2

Rehabilitation

• Begin active toe motion exercises immediately (within comfort limits) to prevent stiffness 2
• Progressive range of motion exercises after initial pain and swelling subside
• Gradual return to activities based on symptom resolution 2

Surgical Considerations

Surgical intervention is generally not required for minimally displaced fractures of the distal phalanx 3. However, surgical treatment may be considered in specific circumstances:

• Fracture displacement involving more than one-third of the articular surface 4
• Unstable fracture pattern with progressive displacement on follow-up imaging
• Significant functional impairment despite conservative management

If surgery is deemed necessary, options include:

• K-wire fixation with extra-articular technique to avoid joint damage 5
• Exact reduction and internal fixation for optimal functional outcomes 4

Follow-up Protocol

• Clinical and radiographic reassessment at 2-3 weeks
• Evaluate for:
  • Fracture healing progression
  • Maintenance of alignment
  • Range of motion
  • Pain control
• Continue buddy taping for 4-6 weeks total depending on healing progress
• Full recovery typically expected within 6-8 weeks

Important Considerations and Pitfalls

• Avoid excessive immobilization: Risks include joint stiffness, muscle atrophy, and chronic pain 2
• Monitor for complications: Watch for signs of malunion, nonunion, or post-traumatic arthritis
• Patient education: Emphasize the importance of compliance with buddy taping and early motion exercises
• Special populations: Consider modified approaches for patients with diabetes, peripheral vascular disease, or other comorbidities that may affect healing

By following this algorithmic approach to management, most minimally displaced intra-articular fractures of the distal phalanx will heal with good functional outcomes and minimal complications.