What is the appropriate treatment for a hallux (big toe) fracture?

Management of Hallux (Big Toe) Fracture

The appropriate treatment for a hallux fracture includes immobilization with a walking boot, limited weight-bearing with wheelchair assistance for three weeks, ice application, and pain management with ibuprofen and acetaminophen, with follow-up radiographs at 30 days to assess healing. 1

Initial Assessment and Imaging

• Obtain standard radiographs including:
  • Anteroposterior (AP)
  • Medial oblique
  • Lateral views
  • Consider weight-bearing views when possible to detect dynamic abnormalities 2, 1
• If radiographs are negative but clinical suspicion remains high, consider advanced imaging:
  • MRI is the preferred second-line study for suspected occult fractures 2, 1
  • CT may be necessary for complex injuries or preoperative planning 2, 1

Treatment Protocol

Conservative Management (Most Hallux Fractures)

1. Immobilization:

   • Walking boot to protect the fracture site and limit motion 1
   • Duration typically 4 weeks for uncomplicated fractures 1

2. Weight-bearing restrictions:

   • Wheelchair assistance for first 3 weeks to limit weight-bearing on the affected foot 1
   • Progressive weight-bearing after initial immobilization period

3. Pain management:

   • Ice application to reduce swelling and pain
   • NSAIDs (ibuprofen) and acetaminophen for pain control 1
   • Avoid opioids due to potential risks 1

4. Follow-up:

   • Clinical and radiographic follow-up at 30 days to assess healing and maintained alignment 1
   • Additional imaging may be necessary if healing is delayed

Special Considerations

Seymour Fractures (Open Physeal Fractures)

• These are open physeal fractures of the distal phalanx often associated with nail bed injury 3, 4
• Require prompt diagnosis and treatment to prevent complications like:
  • Infection
  • Osteomyelitis
  • Malunion or nonunion
  • Premature growth arrest 4
• May require surgical intervention with suture stabilization rather than conservative management 3

Sesamoid Fractures

• Rare but can occur in association with hallux injuries 5
• May require surgical intervention (extraction of fragments) if nonunion develops 5
• Present with localized pain and tenderness at the base of the first metatarsal

Rehabilitation Protocol

Phase	Timing	Interventions
Initial	0-3 weeks	Walking boot, wheelchair assistance, ice, NSAIDs
Intermediate	3-6 weeks	Progressive weight-bearing, gentle toe mobilization
Advanced	6+ weeks	Return to normal footwear, strengthening exercises

• Early mobilization should be initiated as soon as pain allows to prevent stiffness 1
• Avoid prolonged immobilization to prevent deconditioning 1

Monitoring for Complications

• Watch for signs of:
  • Delayed union or non-union
  • Post-traumatic arthritis
  • Persistent pain or instability 1
  • Approximately 20% of patients may experience chronic pain 1

Return to Activity

• Traditional protocol: Return to full activity in 18-19 weeks
• Accelerated protocol: Return to full activity in 13-14 weeks 1
• Return to activity should be guided by:
  • Resolution of pain
  • Radiographic evidence of healing
  • Restoration of range of motion

Prevention of Future Complications

• Appropriate footwear
• Gradual increase in activity intensity
• Address any biomechanical abnormalities 1

Remember that any increase in pain during treatment progression suggests overloading and requires temporary reduction in activity 1.