What are the discharge instructions for a patient with a comminuted fracture involving the base of the great toe metacarpal bone consistent with a Salter-Harris type II fracture from the Emergency Department (ED)?

Discharge Instructions for Salter-Harris Type II Fracture of the Great Toe Metacarpal Base

Patients with a comminuted Salter-Harris type II fracture of the great toe metacarpal base should be discharged with instructions for protected weight-bearing, proper immobilization, multimodal pain management, and a structured follow-up plan to reduce morbidity and improve long-term outcomes.

Immobilization and Weight-Bearing Instructions

• Immobilize the fracture with buddy taping to the adjacent toe and provide a rigid-sole shoe to limit joint movement 1
• Weight-bearing as tolerated unless otherwise specified by the treating orthopedic surgeon 2
• For pediatric patients with Salter-Harris fractures, immobilization is particularly important to prevent growth plate disturbances 3, 4
• A walking boot or cast may be necessary for more unstable fractures

Pain Management

• Primary analgesia should be acetaminophen (first-line) 2
• Avoid NSAIDs, especially in patients with renal dysfunction 2
• Avoid opioids when possible due to risk of side effects 2
• Apply ice for 15-20 minutes every 2-3 hours for the first 48 hours to reduce swelling and pain

Wound Care (if applicable)

• Keep the area clean and dry
• Change dressings as instructed, typically every 1-2 days
• Monitor for signs of infection: increasing pain, redness, warmth, swelling, drainage, or fever
• Elevate the foot above heart level when resting to reduce swelling

Follow-Up Care

• Schedule follow-up appointment with orthopedics within 7-10 days
• Obtain follow-up radiographs at the appointment to ensure proper alignment and healing
• For pediatric patients with Salter-Harris fractures, more frequent follow-up may be necessary to monitor for growth disturbances 3, 5

Rehabilitation Plan

• Begin appropriate range of motion exercises as directed by the treating physician to prevent stiffness and muscle atrophy 2
• Physical therapy should be initiated after appropriate healing, typically 2-3 times weekly initially 2
• The goal of rehabilitation is to return the patient to pre-fracture levels of activity 2

Warning Signs (Return to ED if):

• Increasing pain not controlled with prescribed medications
• Numbness, tingling, or blue/white discoloration of the toes
• Signs of infection (increasing redness, warmth, drainage, fever)
• Cast or splint becomes loose, wet, or damaged
• Inability to move toes or significant increase in swelling

Special Considerations for Pediatric Patients

• Salter-Harris fractures involve the growth plate and require special attention to prevent growth disturbances 3, 4
• Most children with physeal fractures should be referred to orthopedic specialists for close monitoring 1
• Parents should be educated about the potential for growth disturbances and the importance of follow-up appointments

Thromboprophylaxis (if indicated)

• For patients with limited mobility or additional risk factors, consider thromboprophylaxis with compression stockings 2
• For higher-risk patients, pharmacological prophylaxis may be considered 2

Activity Restrictions

• Avoid sports and high-impact activities until cleared by the treating physician
• Avoid prolonged standing or walking for the first 1-2 weeks
• Gradually return to normal activities as directed by the orthopedic specialist

This structured approach to discharge instructions ensures comprehensive care for patients with Salter-Harris type II fractures of the great toe metacarpal base, focusing on preventing complications and optimizing long-term functional outcomes.