What is the treatment plan for a proximal phalangeal fracture of the second toe?

Treatment Plan for Proximal Phalangeal Fracture of Second Toe

For a proximal phalangeal fracture of the second toe, conservative management with buddy taping to an adjacent toe and protected weight-bearing is the recommended treatment approach.

Initial Management

• Pain Control:

  • Implement multimodal analgesia immediately 1
  • Regular paracetamol/acetaminophen
  • Cautious use of opioids (especially with renal dysfunction)
  • Consider regional nerve block for severe pain

• Immobilization:

  • Buddy taping to adjacent toe (typically third toe)
  • This provides adequate stability while allowing for some functional movement
  • Prevents rotational deformity and promotes proper alignment

Treatment Approach

Conservative Management (Primary Approach)

• Indicated for most proximal phalangeal fractures of the toes that are:

  • Non-displaced or minimally displaced
  • Stable
  • Without significant angulation or rotation

• Specific Techniques:

  • Buddy taping to adjacent toe with gauze between toes to prevent skin maceration
  • Rigid or semi-rigid shoe with a wide toe box
  • Protected weight-bearing as tolerated
  • Ice and elevation in the acute phase to control swelling

Surgical Management

• Reserved for fractures that are:

  • Significantly displaced
  • Unstable
  • With severe angulation or rotation
  • Open fractures
  • Associated with joint involvement

• Surgical Options (rarely needed for toe phalangeal fractures):

  • K-wire fixation
  • Mini-fragment screws
  • Intramedullary fixation

Rehabilitation Protocol

1. Weeks 1-2:

   • Protected weight-bearing with supportive footwear
   • Elevation and ice to control swelling
   • Gentle toe range of motion exercises if pain allows

2. Weeks 2-4:

   • Continue buddy taping
   • Progressive weight-bearing as tolerated
   • Increase range of motion exercises

3. Weeks 4-6:

   • Discontinue buddy taping if fracture shows clinical stability
   • Return to normal footwear as tolerated
   • Begin strengthening exercises

Follow-up Care

• Clinical assessment at 2-3 weeks to ensure proper alignment
• Follow-up radiographs only if clinical concerns arise (persistent pain, deformity)
• Expected healing time: 4-6 weeks for clinical union

Special Considerations

• Diabetic Patients: Require more vigilant monitoring due to risk of delayed healing and potential for Charcot neuro-osteoarthropathy 2
• Athletes: May benefit from more rigid immobilization initially, with carefully supervised return to sport

Common Pitfalls to Avoid

• Overtreating: Most proximal phalangeal fractures of the toes heal well with conservative management
• Prolonged immobilization: Can lead to stiffness and delayed return to function
• Inadequate pain control: May lead to poor compliance with weight-bearing instructions
• Neglecting proper footwear: Appropriate footwear is crucial for protected weight-bearing and preventing further injury

Unlike proximal phalangeal fractures of the hand which often require more aggressive management including open reduction and internal fixation 3, 4, 5, toe fractures generally respond well to conservative treatment due to the lower functional demands and inherent stability provided by adjacent toes.